Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"o FL-STOCKTON CA 95202 -(209)468-3420 <br /> tl� NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> N. , > <br /> JOB ADDRESS 1` . CITY/ZIP <br /> Q Y <br /> t <br /> CROSS STREET �At AA ,r��/' �/l� APN 013—2'--O—t/� PARCELSIZE <br /> 9,5-{AfVY <br /> p <br /> OWNER NAME. an PHONE <br /> OWNERADDRESS CITY/STATE/ZIP <br /> CONTRACTOR -'C�ipNj AV B&vw UPHO 0 -3 13 <br /> CONTRACTOR ADDCITY/STATE/ZIP s3tli0 <br /> RRE <br /> SUBCONTRACTOPHONE <br /> ` SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 0 C-57 C-61 0 D-09 %2ther 1� 0 NUMBER EKPIRATION DATE �+ <br /> GEOGRAPHICAL IN ORMATION: Coordinates X V Township Range Section <br /> INTENDED USE mestic/Private 17 Irrigation/Agricultural ❑Industrial O Water Quality Monitoring 0 Soil Sampling/Characterization <br /> alas O Public Water System <br /> ublic:W ter Owner: mer ysmm Nam onracr ame or ne No <br /> TYPE OF WORK ❑New Well 0 Replacement Well 0 Well Alteration/Modification 0 Test Hole ❑Other <br /> 0Monitoring Well(s) numberofwns 11 Soil Boring(s) —berofborings 0Geotechnical numberofborings <br /> a. 0 Well Destruction 0Out-Of--Service Well 0Out-Of-Service Well Renewal <br /> 0 New Pump kPump Replacement 0 Pump Repair 0 Cross-Connection Repair <br /> WELL CONSTRUCTION <br /> Drilling Method 17 Mud Rotary O Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other <br /> Proposed Well Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> 0 Conductor Casing in diameter / Conductor Casing Depth tl <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth ft 0 Neat Cement(94 l6 bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br /> 0 Bentonite(20%solids) 0 Manufacturer Spec%solids % Name 0 Specs on File 0 Specs Submitted <br /> bin Grout Placement Method 0 Pumped 17 Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed BY 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal Dimensions: Width fl Length ft Thick 0 Christy Box 0 Stove Pipe <br /> PUMP OxSubmersible 0 Turbine 0 Other HP Pump Set it Standing Water Level ft <br /> Iwo WELL DESTRUCTION 0 Open Bottom 0 Gravel Pack 0 Uncased 0 Other <br /> Well Diameter in Total Depth ft Depth to Water ft 0 Casing to be Perforated from ft to ti <br /> Sealing Material 0 Neat Cement(94/A hug/5-10 gal water) 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 0 Specs Submitted <br /> tr Placement Method 0 Pumped 0 Free Fail 0 Other <br /> 0 Complete with Mushroom Cap ft below grade 0 Complete to Existing Surface Pad <br /> 1 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. 1 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 <br /> an WORKERS COMPENSATION LAWS. <br /> IMUM 24 OUR A NCE OTICE REQUIRED F/O INSPECTIONS—PLEASE CALL(209)9 /016 <br /> /5'3-7 97 <br /> SIGNEDrvu TITLE V PATE <br /> l <br /> r <br /> 1� F I I BLICEIVED <br /> J 0 IN 0 N <br /> cc <br /> inn FPA HE TH DIVI 10 <br /> a. <br /> A/v DEPARTMENT USE ONLY <br /> It. <br /> t— <br />