SU0009784 SSNL - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMIT WAONCOUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE 3—FL-STOCKTON CA 95202 - (309)468.3420 NON-REFUNDABLE PERMIT CALL,4209)953-7697 FOR INSPECDDNs EXPIRES 1 YEAR FROM DATE ISSUED �c^ o s Esc o TSD p� )n 9�i33C-, JOBADDRESS f..7 CROSSSMEET en fr'SrO r APIN /G/--12O�104AB:EL SI2B -" LAND USE APPLICATIONN OWNERNwn1E PRONE OWNERADDRVS e CRV/STATVZIP CONTRACTOR II /PULS rLIIIPuone�_?'2 CONTRACTOR ADDRESS 1 Iba,,r ISFY CrPvISrATEtZD i • J//krfma-, SUBCONTRACTOR PHONE SUBCONTRACTORADDRE[S CrTv1STATE/LP UC[rvse C-52 OCSI OD-09 OOmer NUMBER EXPIRATION DATE GEOGRAPHICALINFORMATION: Coordinates X V Townahlp_ Rage_ Seetlon_ INTENDED USE tic pm.te ❑Irrigation/Agricultural Q Industilel ❑Water Quality Moniwing ❑Soil Sampling/ClunaCTMIDnOn ❑Public Water system IfdiMI.Wnm0_ a„ ,_ ane �e un�une ar�wne uA TvrE OP We"OdL.Well ❑Replacement Well O Well Alteration/Modification O Test HOk 11 Other ❑Monitoring Well(s)__NOfwellS OSoil Bodng(s) aaborim 0Oarahnical nature, O Well Dourn"we OOut-Of-Smice Well OOutOf-Service Well Renewal O New P..p O Pp Replacernam O Pump Repair O CroarConnwFon Repair WELLCONFTRUCTION Denting Method O Mud Rou,.q 13 Air Rourr, O Auger O Cable Tool CI Push Poi" O Other m Proped Well Depth ";�[ R Eanveaan_�_i radiometer ❑Open Bmtwn Arl"Nvel Pack/Gravel Sia indimuctur ❑Conductor Casing In diameter / Cmtductor Cahn Depth _ft Wall Caen, Diameter Thicknea4Gau9e/ASTM Scheel OSteel .vA4laslic 0suinlea Sral OOthe, Grout Seel D th ft ❑Neat C=cni(9416hag/5-IOgalwaTrr) LISfand Cement .cock rain/7gal—w >"`enunite(20%wlidS) OManuacwWSpec%Soilds % Name _ ❑Spas M File E3 Spans SubmistN Gnat Placement Method ❑pumped ❑Fra Fell OOther ❑Reutdant/Aatlmmr(ame) PEDESTAL Iwtalled By ❑Driller p Contractor ❑Other Q5 1 O Concrete Pedeaul Dimensions: Wid R Largth R Thick OCbdrIy BST ❑Stove Pipe PUMP 0Submcrsiblc 13 Turbine OOther_ HP Pump Set_ft Sanding Warm Level R WELLDERIRUC N El Open Bottom 00.6 Pack 13Unuad C!Other Well Diameter in TOUT Depth R Depth on WSW ft O Casingto he Perforatd Rom_Bm R �(') Sealing Materlal ❑Nat Cemew(W IA b"/540 ge/ware') ❑Send Concert sack mix/5 IweW, 0Bmmoile PMkta ❑ecrannite(2WA solids) ❑Manufacamr Spa%mlids__% Name OSpecace File 13 Spaces Submitted _ Plesement Method ❑Pumpd O F.Fell O Other _ ❑Complete with Mushroom Cap R below grade ❑CorrlpleR toExisting Surface Ped s I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ORDANCE WITH SAN L JOAQUIN COUNTY ORDINANCES. STATE LAWS,AND RULES AND REGULATION& 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNEDV L L //L.�f./� TrrLe 111,41 N DATe �eS Z7o e+� 3 tel c Sys AL DEPARTMENT USE ONLY Application Acneptd BY Dow Z/LSO/ _ ATa 2.11 Emplora lwr e4w� ��y Grout InepaV.Byenpl_ Date 7 Z O SPECIAL Well Permit Pump Inal'ation ey Date ❑ WAIVER Recelved Destruction aryaROn By Date Constructed Well Depth_ D COMMENTS GiYCY «pci lb G �Llsr-r�1'G1L 6L�r/l L.J�'6L/iK,/n/n. li L[:tT2.1? AP nr/ R EAcr'tk. SC Received Idl/ Amount pate Involcap Wee lm Coda Info B emiHed Service umtg 4d.bG ItU azsw / ! O b Z ENOOaraa //T G MiI�: /vim wwTsa wsu PMtwrt naTTKo3 ,5y71'1; //LSZn 6e A k 3rr�s;rL GAL5 a6Sd