Laserfiche WebLink
03z) <br /> WELL / PUMP PERMIT `' ' <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"D FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> �j �Ll <br /> Cq <br /> JOB ADDRESS \ IV ' "Z t r CITY/ZIP _ ' " �'I� <br /> CROSS STREET lJ- `` ' APN 6^ PARCEL SIZE Y` LAND USE APPLICATION# <br /> fly _ 11 1 \' n � <br /> OWNER NAME .U• �AH�,ly PC,r l W,--s h (� ( V CT✓l c A, t�G 2 , PHONE ao(/ (� /—`I J_73L) n <br /> OWNER ADDRESS a 1. � S `uv ` CITY/STATE/ZIP S tl lv c-14 [� �a / <br /> CONTRACTOR `W' ��t�' `�hY PHONE aa1Q— <br /> �' Za CITY/STATE/ZIP L14, CVt� gS334 <br /> CONTRACTOR ADDRESS O. /� � <br /> SUBCONTRACTOR lL PHONE �/q '_':3 z� <br /> SUBCONTRACTOR ADDRESS CATV/ST/A(TE/ZIP V <br /> LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER 1�SD p EXPIRATION DATE0S/Z 0 0 CA Cb <br /> ^ ' <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section `v <br /> INTENDED USE ❑Domestic/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 ❑New Well ❑Replacement Well 16 Well Alteration/Modification Jd Other jjl V61 IVJ TOS 1; ^ <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) n of borings ❑Geotechnical of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION W/A <br /> Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL V/,A-- Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width tt Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP L/ ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKTION LAWS. <br /> MIN UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED= TITLE O C.V z--4e57/_._ DATE G <br /> E ' <br /> S N <br /> E VI O N <br /> I ti E A TMFN- <br /> +H I . f+ <br /> D E A T M E N T USE N L Y <br /> c y(� <br /> Application Accepted By_ ��� Date Area Employee ID# <br /> Groutlnspection By i 42- Date ❑ SPECIAL Well Permit <br /> �nspechon Date ❑ WAIVER Received <br /> Constructed Well <br /> Depth ft <br /> COMMENTS <br /> 'z; Afv��.:J-q.t .Al ��/ �III1l��X�%. <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted rvice Request# <br /> 1-7 <br /> Cny '�'�6 WCI 1 DI IMD OCD�IIT <br />