Laserfiche WebLink
' .�O WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3°°FL-STOCKTON CA 95202-(209)463-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES <br /> 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS r rt - .CITY/zIP cerf m <br /> l <br /> / e9r] C <br /> CROSS STREET 13 <br /> APN B/b/� -�PARCEL SIZE ('7'4 LAND USE APPLICATION# <br /> S7 <br /> OWNER NAME �✓�.L/-/�� A ��TT�F.'- PHONE (Vl�/'� T'`�'✓t:/ f� <br /> OWN RADDRESS l!/�J1 SOX }��`�f/ CrrY/STATEIZIP ✓ <br /> CONTRACTORl,J�P' PHONE GL <br /> CONTRACTOR ADDRESS I l & I L/LY✓`C M. CITYISTAT,,z P -P1 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE 1OD,7 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ <br /> INTENDED Use Domestio[Nvau ❑Irrigation/Agricultuml ❑industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> Ydiir°rem Dom arm yaemNa— Iact eme or one u r <br /> TYPE Or WORK)(New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) N of wells ❑Soil Boring(s) x otboringr ❑Geotechnical x°tborinp <br /> ❑Out-0f-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Propowd Well Depth CkZ JVO ft Excavation 49 in diameter ❑Open Bottom Gravel Pack/Gravel Siu in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6 in Thickness/GaugdASTM Sched 1lp e ❑Steel *lastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(9416 bag 15-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> entoniu(20% <br /> rosolids) ❑Manufacturer Spm%solids_% Name ❑Specs on File ❑Specs Submitted (= <br /> Cut Pincement Method Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller >Pump Contractor ❑ Other <br /> ❑Cotterete Pedntal Dimenaiona:Width ft Length it Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑OtherHP Pump Set ft Standing Water Level ft p <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN G' <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE 1S <br /> • CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS m <br /> ��MINIMUM <br /> ,rI N IMUMn24 HOUR ADVANCE NOTICE REQUIttE'P�FOR INSPECTIONS <br /> SIGNED 1A`C,� /Y La')A,�JGIS TITLE NII/CM DATE <br /> Ir N-Ir 17 <br /> i <br /> UI COL <br /> EN i <br /> DEPARTMENT UE ONLY �L <br /> Application Accepted By Date �2- G Area EmployeeIDN <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By ex Dau ❑ WAIVER Received <br /> Constructed Well Depth It ,,�fD <br /> COMMENTS A)EW I- <br /> PE <br /> PE SC Recdved Chec Amount Permit/ <br /> Coda Info a tete eoonttted Date Service Request# Invoke# Well IDN <br /> �3 vGr )kt) S7�1rU 3zs.r� �( � <br /> • <br /> END 4342-0D6 WELL PUMP PERMIT <br /> If]]2005 <br />