Laserfiche WebLink
r WELL/PUMP PERMIT <br /> SAN JOAQt1LN COUNTY ENVIRONxIENTAL HEALTH DEPARTMENT 600 E.Aa'MAIN STREET-StOCKTON CA 95202-(209)46$•3028 <br /> NON-REFUNDABLE PERMIT x EXPIRES I YEAR FROM DOTE ISSUED <br /> "JOB ADDRESS <br /> uST- CITyrw I cA 9 <br /> CROss STRELT -� 192 >#I�L��[�$V� �d� — APv o 3���► PARCEL SIZE <br /> Fa <br /> OWNERNAME +"a�--'yV I(JU—AQL LJ—��,`2C4. PRONE 0tL6--=_R W— K <br /> OwNuA.Owtm t✓ �x cn>s /JCITYL." <br /> ISTATFJZIP �-�c�j),IDI / <br /> "(����-� r�- <br /> CONTRACTOR u ��_ IPHONE.I 5 DptL ZqqI)tr <br /> CONT0.4,CrORADDPM tQ��6 C, <br /> SUaCOr.TRACTost PHONE <br /> SUBCONTRACTOR ADORES$ CITY/STAT,EIITJP <br /> LICENSE ❑C-57 -61 ❑D-09 ❑Otho Nu,%WER 1 l ExPix%Tio%D.vTE <br /> GEOGRAPwCALINF*Rxi.irtON: Coordinates X _ Y _ Township_ Range Seettan__ <br /> INTENDED USE 'c.Privat, ❑hrigatimAgricutpRal ❑Industrial ❑Water Quality Monitoring ❑Soil SamplinaChaructmuatioo <br /> ❑Public Water System <br /> V diBer�a freo:Owae;- W:aer Sysrcm Vmn Comae Vamr a•1'}wea Number <br /> TYPE OF WORK ❑New Well ❑Replacement Weil ❑Well AlteratioMModiflMion O Test Hole ❑Otter <br /> ❑Monitoring Wells) nambcofw•Rc ❑Soil Bonin 60�"`HbD11rg' ❑Geotechtrieal oumtr.an.,ing: <br /> ❑Well Destruction O Out-OfScmice Welt ❑Out-Of-Sen ice A-cll Rcw%W <br /> Ati'w pwv Replacement ❑Pump Repaw ❑Cross-Connection R. <br /> pair <br /> WELL CON'STAtiCrloN <br /> DrM g Merited ❑Mud Rotary ❑Air Rotary ❑Anger ❑Cable Tool ❑lash Pour ❑Other <br /> Prod Well D9Mh R Excavation in diameter O Open Bottom ❑Gravel Pack i Gravel Sue in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Wd1 Casing Diameter_in 7bwknm4GauWASTM Schell ❑S.eel ❑Plasia ❑Stainless Steel ❑Other <br /> Grout Seal Depth R ❑Nest Cement 1941&bag'S-IOSW worry ❑Sand C-mctm sack nfir;7 gal water <br /> ❑Beruonite(2014 solids) ❑Manufacturer Spec%solids_S5 \ass ❑Specs on File ❑Specs Submitted <br /> Grout Pbeemeat Method ❑Pumped ❑Free Fall ❑Other ❑Retardant:Accelerator(name) <br /> PEDMAL Igo ❑Lkiller ❑Pump Contractor ❑Other _ <br /> ❑Concrete Pedestal Dimensions: Widtb_,ft Length_ft Thick in ❑Chrkt.V Box ❑Steve <br /> Pipe <br /> PUMP ubmersible ❑Turbine ❑Other HP_�_ Pump Set R Standing Wates Lead ft <br /> WELL DtsrnucnoN ❑Open Boncwn ❑Gravel Pack L7 Uncescd ❑Other a <br /> Well Diameter_in Total Depth ft Dgrth r Navr fl ❑Casing t <br /> to be Perforated from fl w h <br /> $nl,ng MAtertai ❑%cat Cement(941b bag,5-10 gal cuter) ❑Send Coraot sack m1:17 gal water G Bentonite Pallets <br /> ❑Bentonite 120%solids) O Mamdacwrer Spw%solids_% Name ❑Specs on F'tc ❑Specs Subtn ucd <br /> Peaatueat Method ❑Pum Cl Free Fall ❑Other <br /> ❑Co left with 3fusbroom Cap fr hcbw ❑CousiIete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQCURRENT <br /> COUNTY ORDIN �S STA ORNtA A CONTRACTORS STATE LES ANDRECAlLAT'OON BOARD AND I HA LSI CO EQVff tED <br /> NCELICENSE IS Pq}�01 <br /> CURRENT AN ACTIVEALSOTIFV 'Pl <br /> woR�c z RFCF%�T <br /> T.T. `� � DATE — D-17 Sj <br /> ?p <br /> N� hIRChM CQ� <br /> M� <br /> 01V I <br /> CIV ® <br /> P `t 5 2017 <br /> ONMENTAL HEALTH <br /> RMiT/SERVICES <br /> 14 El <br /> r . •DEPARTMENT ASK ONLY C G ",1 <br /> Applicaten Asxx pled By Date r--S 'f l Area (- VV(J/� <br /> 1 E�oyee!D# <br /> Grout Inspection B}' Date=-f,� t`- 1 ` " 0 SPEC[AL Well Pei'IDlt <br /> Pump lesp-ion By 1 pate r' p WAIVERReceived <br /> Destruction Inspection By Dar Constructed Well Depth h <br /> COhDwENfS <br /> PE 9C <br /> Permw <br /> Codes Iota Reolk_dwdCIA I Rmaktoe Dtlr Sema y Invoke# Won 1D# <br /> t <br /> END 43-02-006 WEB - <br /> 9a I<2007 Well Pemar and Decbtstion.doc <br />