Laserfiche WebLink
WELL 1 PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER;-..i 3R"FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES ] YEAR FROM DATE ISSUED <br /> QI �]�O 44 �+ C H <br /> JOB ADDRESS I Vl lT __ CITY/ZIP Qirlc O'!� t S Z J m <br /> a <br /> d <br /> CROSS STREET L tj keep APN 103`056-M PARCEL SIZE tL4`t4, LAND US PA N# <br /> Y <br /> OWNER NAME { �}SCC" t 1 S PH � <br /> ON _t L t <br /> OWNER ADDRESS `0?^1!� _ s� W�/Clh CITY/STATE/ZIP �L � �"�J <br /> CONTRACTOR ti`�wSi�t tf ,Jr� k\% -f PE C <br /> CONTRACTOR ADDRESS V 1 Ty 16e-r S ryv�HONP-CA. CITYISTATE/ZIP_ ,AZ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTATE/ZIP <br /> LICENSE "IKC-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section <br /> INTENDED USE 1913omestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> if different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK JNCNew Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> ❑Monitoring WeII(S) #of wells ❑Soil Boring(s) 9ofborings <br /> ❑Geotechnical a of borings <br /> ❑Well Destruction ❑put-Of-Service Well ❑Out-Of-Service Well Renewal <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUC�]'IOyN <br /> Drilling Method1ZMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth *"C) ft Excavation I—L in diameter ❑Open Bottom Gravel Pack/Gravel Size' in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> h Well Casing Diameter lc;p in Thickness/Gauge/ASTM Sched 1 C"r-> ❑Steel Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth l(SC) ft ❑Neat Cement(94!h hag/S-10gal water) ❑Sand Cement vack mix 17 gal water <br /> KBentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall '❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By. ❑Driller ❑Pump Contractor ❑Other <br /> ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove,Pipe <br /> PUMP ❑Submersible ❑Tutbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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 {rj <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED ��. tN►+r--�� TITLE IJ r i Ef f-P-,— DATE <br /> S <br /> � 2 <br /> ar a <br /> y � <br /> s <br /> N JOA.DU,N qOLN 2 <br /> lEtt:�NMtN <br /> Application Accepted By Date ! ( ds Area z r Employee ID# <br /> Grout Inspection Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth fl <br /> COMMENTS OL-0 LU-t OF E?ECt7��S <br /> PE SC Received heck#/ Amount Date Permit/ Invoice# WelI1D# <br /> Codes Info B as Remitted Service Request# <br /> 4-3-(06 18U 0 N-77 I <br /> e _ _ <br /> EiI()41-02-Ooh K�7'// /!mo=d Cfi�7J" '�`� ��� WELL PUMP PERMIT <br /> R16;04 <br />