Laserfiche WebLink
`` WELL/PUMP PERMIT <br /> i J l'-'.SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPAwrmENT 301 E WEBER AVE 3-FL-STOCKTON CA 95267 -(209)4"-J 47U <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES f YEAR FROM DATE ISSUED <br />' <br /> JOBADDRESS Crrv/ZIP <br /> 8 00 9chilersto R� _ <br /> _ f <br /> CROU STREET O n APN W - 1-10 4 PARCEL SIrX <br /> OWNER NAME r'1 (11rL IR PHONE r�1 C <br /> OWNER ADDRESS L V V r V CITYIStATE(LIP 1{,1 �+ <br /> CONTRACTOR _L L�l(a.S,S QrJ�r,� , A& PHONE Xo> <br /> �/ /Lr <br /> CONFIUCrOR ADDRESS � F n r e_ .r CITYISTATEfLIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADORES$ CITV/STATEQIP <br /> LICENSE XC-57 OC-61 0D-09 17 Other NUMBFA ExpIRATiON DATE J <br /> Pr+ <br /> GEOCRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section CCs <br /> INTENDED USE q DomestirJPrivate C1 Irrigation/Agricultural O Industrial O Water Quality Monitoring q Soil SamplinlyCltamclCli7alion p� <br /> O Public Water Syyssttecm <br /> If diffnent from l']wree: tem Nom C.Atwt .me ar N.. <br /> TYPE OF WORK 0 New Wel]- O Replaccmcnt Well .0 Well Alteration/Modification 0 Test Hale 0 Other - �} <br /> OMonitM,,Well(a) Aumberarmis 0Soil Basin aumarr afbo ingr wmaer ot6m �• <br /> . g(a) OOcotechnical r'n <br /> 0 We11 DcstruariDn 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal <br /> 0 New Pump 0 Pump Replacement 0 Purnp Repair [3 Crus-Connection R it <br /> WELL CONYMUCTION <br /> Drilling Method O Mud Rotary ❑Air Rotary Cl Auger 0 Cable Tool 0 Push Point 13 Other Q <br /> Proposed Well Depth R Excavation in diameter 0 Open Bottom 0 Gravel Pack f Gravcl Sim in diameter <br /> 0 Conductor Casing in diameter I Conductor Casing Depth R <br /> Well Casing Diameter_in Thickness/OsugdASTM Schell 0 Steel 0 Plastic 0 Stainless Sum] 0 Other <br /> Grout Seal Depth R O Neat Cement(941h hug/J-!0 barl trvrer) q Sand Cement rock mix 17 pi water <br /> ClBentonite(20Y•solids) 13ManufacturerSpec%solids_% Name OSpecsonFila 0SpecsSubmitted <br /> Grout Placement Method 0 Pumped 0 Frye Fell 0 Other q Retardant!Accelerator(acme) <br /> PEDESTAL InsfAIIIIA B O Dhller D Pump Contractor 0Other <br /> 0 Concrete Pedestal Dimensions: Width_k L engrh_R Thick in 0 Christy Box 0 Stove Pipe <br /> Pu ❑Submersible 13 Turbine 0 Other HP Pump Set R Standing Water Level It r <br /> WELD.Dn-MU'PION 0 Open Bottom 0 Grave]Pack O Uncased 0 Other <br /> Well Diameter_in Total Depth R Depth to Water n M Casing to be Perforated from R to It <br /> Sealing Material ❑Nat Cement 194 th Aog/3-10avu1"jer) 0 Sand Cement sack mix/7 gal water .0 Bentonite Pellets <br /> 0 Bentonite(20%solids) 0 Manufacturer Spec%solids_% Name 0 Specs on File O Specs submilred <br /> Placement Method 0 Pumped 0 Fres Fall OOther <br /> O Complete with Mushroom Cep ft below grade A Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL RE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS <br /> MINIMUM <br /> M224 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED [ems /.3G-'&- TrrLE - <br /> I <br /> E <br /> a <br /> w� <br /> wa <br /> c <br /> n <br /> ar <br /> Y Application Accepted By Ir <br /> aIDN <br /> 1 - — ' <br /> Area mployee IDA3tO <br /> Grout Inspection By Date ❑ SPECIAL Well Permit , <br /> Pump Inspection By ED , Date ❑ WAIVER Received ! <br /> i <br /> Destruction Inspesron By Dau :a Constructed Well Depth fl I <br /> COMMENTS <br /> PEI SC Amount ec ved Date Permit/ <br /> -ZF21-3 —161E Codes Info Remllted ath B gervlea OWN <br /> Invoice A Well RI)# <br /> It 014ik) c 2 <br /> EMD 43-02.006 <br /> 5I1R002 MASTER WATER WELL PERMIT <br /> i <br />