Laserfiche WebLink
' WELL / PUMP PERNUT Iz F 6scANNED <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH Dhw�TMENT 304 E WEBER A./3ae FL-STOCKTON CA 95202 - (209)469-3420 <br /> NON-REFUNDABLE PERMIT ,t CALL 209 953-7697 FOR INSPECTIONS S7"/Pk 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �O/S Ale, Ori CITv/ZIP S'7Ffi�/Pk m <br /> a <br /> °o <br /> CROSS STREET -SWivtJavL C APN 1�-D�O`©b PARCEL SIZE pe <br /> //�� LAND USE APPLICATION#U LCi <br /> OwNERNAME _ Pa"( 4-c7g&1y PHONE 7177 <br /> OWNER ADDRESS ,taC e-e ///� CITY/STATP/ZIP <br /> CONTRACTOR Ne/I O. AWBYSfT- T 1'[�'iT TYfL PHONE <br /> CONTRACTOR ADDRESS /J/ L CITY/STATFJZIP GD'� `�T 9S-a42 <br /> SUBCONTRACTOR sr"'/1`7 PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 ❑C-61 ❑D-09 ❑Other NUMBER L& 9� EKPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ '� \ <br /> INTENDED UBE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring INSoil Sampling/Characterization <br /> ❑Public Water System <br /> VdiDetamfrom Owner. water system Nam Comact Name or Phom,Numb., <br /> TYPE OF WORK O New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #ofwelis ❑Soil Boring(s) xof borings Geotechnical t!fxofborings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth 5-/S ft Excavation (;V in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sim 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 ❑Nest Cement(94 lb bag/S-10 gal water) /❑Sand Cement sack mix/7 gal water <br /> [IBentonite(20%solids) f¢Manufacturer Spec%solids_% Name /W�� + I t GW PVSpecs 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 ❑Turbine ❑Other HP Pump Set it Standing Water Level ft <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 /> WORKERS COMPE SATION LAWS. <br /> �MInnNIMU UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED (f. TITLE N�[T)✓ 6&o&A#,LgZf)'f� DATE .Z a <br /> J <br /> I I <br /> CIA <br /> O N <br /> VI p M <br /> HEALT <br /> -D I, P -RTM E-r -IISE ONLY <br /> Applications�A}ccepted By \ Date Area Employee ID# <br /> 47fispection Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constroeted Well Depth ft <br /> COMMENTS �L -v S ,(3lNE-f./�L°!�� � le c .,� ' e---,;/T AAA - 7E5- <br /> PE Sc Received ChecW1 Amount Permit/ Invoice# Well ID# <br /> Codes Info B apsh� Remitted Date Service Request# <br /> e�Da-O Jo o <br /> EHD 43-02-006 WELL PUMP PERMIT <br /> In7aoos <br />