Laserfiche WebLink
I <br /> WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AvE 3"°FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR iNSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS O CITYIZIP <br /> d <br /> CROSS STREETUwwo f e li A A. APN - PARCEL SIZE r/.3 LAND USE APPLICATION# Z <br /> OWNER NAME P&LIL-3 - ----- PHONE <br /> ij <br /> OWNER ADDRESS Wt)g f F , L.f-Yr.L�.Rl1f�T CITYISTATEIZIP t(J( ►C��QrJ�}r <br /> CONTRACTOR � <br /> _L11 =v I. �I {�. f�I 1��Y� Sd N C� r <br /> 5 PHONE jPq- Jbr7-- 3-4-61 <br /> CONTRACTOR ADDRESS TN C1TY15TATEIZIP ,,y r L -16 2-40 <br /> ��- <br /> '`` SUBCONTRACTOR If PHONE <br /> F SUBCONTRACTOR ADDRESS l CITY/STATE/ZIP <br /> LICENSE gC-57 ❑C-61 ❑D-09 ❑Other NUMBER 't7 v0 EXPIRATION DATE 6 -06, <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> 1F2%4MqTM% In <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑ n i to tion <br /> I ❑Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> I <br /> TYPE OF WORK 13 New Well ''❑Replacement Well ❑Well Alteration/Modification Otter V �y <br /> 13 Monitoring Wel!(s) #of wells Soil Boring(s) w� <br /> �_ kl e'ng co �Itic�{r I ee np <br /> 17 Out-Of-Service Well ❑Out-Of-Service Well Renewal Uy I yf I i*,R*,Hea 1h Division G <br /> ❑New Pum -1❑PumR R lacement ❑Pump Repair <br /> WELL CONSTRUCTION „` <br /> Drilling Method ❑Mud Rotary ,I❑Air Rotary kAuger ❑Cable Tool ❑Push Point 0 Other <br /> Proposed Well DepthI.S: 4 ft Excavation Ire0 in diameter ❑Open Bottom ❑Gravel Pack 1 Gravel Size in diameter <br /> ❑Conductor Casing in diameter J Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other C <br /> Grout Seal Depth II ft ❑Neat Cement(94!b bag 15-10 gal water) ❑Sand Cement sack mix 17 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> E Grout Placement Method ❑Pumped KFree Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor it} r <br /> ❑Concrete Pedestal Dimensions:Width ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible 0 Turbine ❑Other 4P Pump Set ft Standing Water Level ft <br /> I PREP D H1_ _ATION T E W K D E _AWH <br /> J COUNT RDIN C TAT AND ULES AND GULATIO LS ERTI A Y RE I D LICENSf <br /> A H CA RN CON" L4CTORS S ENSE ARD I M IA H <br /> OR S COMPE A LA <br /> AD' ANCE N RE 1NSPEC io] S I <br /> SIGNED TITLE � � �S21y DATE !Z 2 OG 4 <br /> !I <br /> C-- -aIzZ IE:1-T'o LEU <br /> i� 3970 WrLCOX ROAD <br /> '-- STOCKTOiN, CALIFORNIA Fiipi <br /> YFG• �l <br /> ETL <br /> Hi AL rH E A <br /> p D <br /> Ip <br /> I ,D'EPAR'T_M E N T' U-S E-:0 1v-L'.Y_.,r <br /> Application Accepted By Date S 3 O(p Area Employee 1D# 5 <br /> t <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> III Pump Inspection By �� Date ❑ WAIVER Received <br /> t Constructed Well Depth `t ft <br /> f COMMENTS �I <br /> �I <br /> i <br /> PE SC ReceivedCheck#1 Amount Date Permit/ Invoice# Well ID# <br /> Codes Info vyas Remitted Service Request# <br /> +3 7" fS0 b fl <br /> t <br /> II! <br /> - EHD 43.02.006 I� _ WELL PUMP PERMIT <br /> trnnoos I ' <br />