Laserfiche WebLink
t <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS /}�EX,,PIIRES 1 YEAR <br /> QFROM DATE ISSUED <br /> Joe ADDRESS 132 Y CmZ^rP(�I IaIU rA.. GA 1533 3 ^mp <br /> CROSS STREET ''11IQ//tu APIN ' /PMCEL SIZE A/A LAND USE APPLICATION[Y�,�Q <br /> OWNER NAME fjr�/nQt'�A - 05 rV 1,. P TiTi�'i l (!L`S }f'PHONE )�Q CV(//nom/—�9j oo <br /> OWNER ADDRESS III h[0v6!w� Ra X1.50 FO 150,1.GA I') 30 <br /> 1 ' I�� _ CITYISTATEZP <br /> CONTRACTOR IYOOks1k`-'f_U1��1AP./5�p(7QT '11Q 1'/� �,p, I(�d C,.p PHONE 19142-669-9600 <br /> CONTRACTOR ADDRESS/ II /yD�I•Bk S.RA ISO Crry/STATEZP Falboln3GA q.5630 <br /> SUBCONTRACTOR fVDr-CGd PU�� G W-II I]II111� 11P1LEj HONE(53o)'b�H-5�I <br /> SUBCONTRACTOR ADDRESS CrTY/S11095 <br /> TQATFZP—YrA--Cr—t ll�G� Z q-I3 <br /> LJCENSE X C-57 y C-61 D-09 Other NUMBER 591 ExpIRAT10N DATE Q01/4o <br /> GEOGRAPHICAL INFORMATION: Coordinates X 3q,01"53 Y'I Z 1.6355 30 Township_ Range Section_ <br /> INTENDED USE Domestic/Private X Irriga n/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterizatlon <br /> Public Water System <br /> If different from O«ner er ye em ame eme a orw um <br /> TWE OF WORK X New Well Replacement Well Well AMeralion/Modfiration Other <br /> Monitoring Wells) Mofwells SoilBodng(s) eofbo"gs Geotechnical eofbonrgc <br /> Out-Of-Service Well Out-Of-Service Well Renewal Crass-Connection Repair <br /> it New Pump Pump Replacement Pump Repair i Raise Well Casing <br /> WELL CONSTRUCTION pp <br /> Drilling Method Mud Rotary Air Rotary . Auger Cable Tool Push Point I( Other 1�L-1(PJry- QC)Si?'tr <br /> Proposed WeR Depth00� R Excavation 11It in diameter Open Bottom XGravel?etic/Gravel ze_in diameter <br /> Conductor Casing 14"_in diameter / Conductor Casing Depth T 6D R <br /> Well Casing DiameterLL in Thidmau/Gauge/ASTM Sched 1 I� I Wal Steel Plastic i Stainless Steel Other <br /> Grout Seal Depth 50 R Neat Cement(94 lb bagl5r 10 gar water) X Sand Cement hnN.3 _sack mixn gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method X Pumped Free Fell Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By ADriller X Pump Contractor - Other <br /> Concrete Pedestal! Dimensions:Width R Length R Thick in Christy Box Stove Pipe <br /> PUMP )(Submersible Turbine - Other HP_,3_Q_ Pump Sel R Standing Water Level tt <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI,NIMUM 24 HO VCAp� E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-76971 <br /> SIGNED t �r� TRLE \ Q DATE_Z—2—&t,C <br /> v IVSD <br /> 29 2016 <br /> MENTAL HEATH <br /> PA <br /> IT/SERV7CES <br /> R F. <br /> All <br /> A� <br /> / DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee IDM`u'7" <br /> Grout InspectiQ - _ Dale 77 `.J SPECIALWAIVERWell Permit <br /> Pump InspecGo B Dale 1 [., I/,� WAIVER Received <br /> v l j-i"Crl L� <br /> Soil Boring Inspection By Date� �- Con`atrulded Wen Depth R <br /> COMMENTS l.L`-�l _,IAit.L1,' -yl /`-crn'':,..lY ✓........ 1 '7.'.i l� GGT <br /> r� <br /> PE SC Received /C Amount Date PermlV Invoice M Well IDM <br /> Codes Inco B h Remhted Service Request M <br /> w-)6 nLIC ?171.2 <br /> a�-i7 -1-IL 6c-7 54 L3 <br /> EHO 43-06 WELL/PUMP PERMIT <br /> 4r3W12 <br />