Laserfiche WebLink
t <br /> s, <br /> WELL/PUMP PERMIT <br /> SAN JOAGUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS 30 [ [ F- ,�Ir a er CITY/LP L J C'i i 4.l r7 <br /> CROSS STREET ��'L I-(.1 f QVC'` APN L�� 1{ 5.0,4-4-PARCEL SIZE Zs, LAND USE A/PPLLIICCATTIION# m <br /> OWNER NAME _ /t��4"L - JLa r-yr��J 1 PHONE <br /> OWNER ADDRESS _ Pra~ 'ice' L a CITY/STATE(7JP <br /> J <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS (,'(_/ �-- Ar= r� _i-�/ CITY/STATEIZIP 1 C,!t-Lru(g� <br /> SUBCONTRACTOR _ L(7 PHONE <br /> SUBCONTRACTOR A00 SS /CI�TYI>ST�AJTFJLP <br /> LICENSE 7 C-61 L D-00 Other NUMBER "7/ -/��JC •ExPIRAT10N DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED UsE Domestic/Private gation/Agrkultural L industrial Water Quality Monitoring ' Soil Sampling/Characterization <br /> ,Public Water System <br /> It d,11f from Owner Witter System Navoi contactor PtioneN—tief <br /> TrPEOF WORK _ Well Replacement Well WW AiteraCaNModificat. Other <br /> Motitoring Well(s) #of wells Sou Boring(s) s 01 L.M p Geotechnical r cr Ounrys <br /> Out-Or-Seivice Well Out-Or-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Rotary Air Rotary Auger Cable Tool _.Push Point a Other <br /> Proposed Well Depen "'�n E=ava cors in diameter Open Bottom ravd PackJGravel Size in diameter <br /> Conductor�Casing in diameter / Conductor Casing Depth <br /> Well Casing Diameter • 7in,,TMckness/GaugelASTM Sched Steel �r!'fast mless SIe81 <br /> Grout Seal Depth ft :'�Neat Cement(94 Ib bagrS fO gal water) Cement I Q r ; O ,rri gal water <br /> entonite(2 olds) Other <br /> Grout Placement Method - umped L,Free Fall :j Other -1 R /Accelerator(name <br /> PEDESTAL Installed By L Driller IL Pump Contractor Other <br /> Concrete Pedestal i Dimensions:Width it Length ft Tick in a Christy Box Stove Pipe <br /> PUMP .I Submersible..Turbine �Other HP Pump Set ft Standing Water Level it <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 <br /> WORKERS COMPENSATION LAWS. <br /> MI UR ONCE NOTICE REQUIRED FOR IN$PJECTIONS-PLEASE CALL(209)9 3-3697 <br /> SIGNED �' TITLE DATE <br /> , - DATE ` <br /> s <br /> ENT <br /> ROC <br /> EIVED <br /> 2 0 2014 <br /> I IN COUNW <br /> AL <br /> DEPARTMENT USE ONLY Gam, <br /> Application Accepted By Area C'ql hi Employee ID#It I L ! <br /> Grout Inspection By a 2' ❑ SPECIAL Well Permit <br /> Fhmp Inspection By Date 0 WAIVER Received <br /> Soil���l Booing Ins By Date Co d Well Dept h ft <br /> COMM jek _ -----. <br /> �r G <br /> PE SC Received Amount �� Permit/ Invoiu# Well IDN <br /> Codes Into B Cash Remitted Service # <br /> Request <br /> 0 t$v KI le <br /> I <br /> Em D 43-06 <br /> 4n(W1 WE:L rPUNP PERMIT <br />