Laserfiche WebLink
WELL/PUMP PERMIT L 61,34q <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER Avr 3-FL-STOCKTON CA%202 -(207)469-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-76977 FOR II%sPECTIONS EXPIRfES,1 Y1E1AR F-R.OM DATE ISSUED <br /> JOBADDRESS a I" II41 <br /> 3 S V " l � p rr Cm/Lr .nTti�1't HR4 > <br /> 0 <br /> ivy L — PARCEL SIZE ND USE APPLICATION N <br /> Caoss STREET cJ�9�^P'1/�1I L y { *� _APN � <br /> OWNER NAME Y Q C1 C1 t.A C t'7 V�s'�_'fi I < !lam ��^� PHONE N <br /> OWNERADDRESS l Crrv/ST'ATErZir <br /> Cxrrawcroa ryTLiit /aL,-�✓1 CI JP+HONE�9 <br /> 4:16 <br /> CONTRACTOR ADDRE2 / CrrY/STATEMP / �ft"'o ts <br /> `f <br /> ns <br /> SUBCONTRACTOR PHONE <br /> SuecONTRACTOR ADDRESS Crrv/SrATErLIP <br /> LICENSE C-57 0 C-61 ❑D-09 0 Other NUMBER EXPIRATION DATE Q'v <br /> GEOGRAPHICAL INPORMATION: Coordinates X Y Township_ Range Sectba <br /> INTTNnr,L isr ❑Domoue/Pnvate O Irription/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Characterinuon <br /> - - - 0 Public Water System o.uct mx <br /> If difrertat fmm 0— am, <br /> TYPE OP WORK 0 New Well 0 Replacement Well 0 Well Alteation/Modificautm 0 Other s orhorinp <br /> �Geotahnical <br /> ❑Monitoring Wells) N of wells 13 Soil Boring(s)ng(s) s ofbo..V <br /> 0 Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Crow-Connection Repair <br /> ❑New Ptunp 0 Pump Replacement ment 0 Pump Repair <br /> wEr 1 r•oNyTatK-Tlon 111 <br /> Drtillag Method 0 Mud Rotary1/10 Air Rotary (Auger d, [I Cable Tool 0 Push Point 0 Other <br /> Proposed well Depth ft Excavation_�j_-in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sitt in diameter <br /> ❑Conductor Casing in diameter / Conductor Cuing Depth ft <br /> Well Casing Diameter_in Thickness/Gaugc/ASTM Schell 0 Steel 0 Plastic 0 Stainless Steel 0 Other <br /> Gout Seal Depth ft 0 New Cement(94 lb bag/3-10 gal louder) O Sand Cement sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Mmufictwc Spa•/.solids % NameF <br /> Jo Specs on File 0 Speer Submitted <br /> Grout Platemeat Method ❑Pumped ❑Free Fall 0 Other 0 Rctardant/Accc=1( ) <br /> pjpEFrAL laatalkd By 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal Dimensions:W141th ft Length ft Thick to 0 Christy Bos ❑Stove Plpe <br /> Pt M► 0 Subnxmble 0 TurbuIc 0 OtherHP Pump Set ft Standing Watt 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 I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIPORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> Nil IMU 24 UR ADVANCE NOTICEREQUIREJI7/�]FOR(INS PECTI S <br /> ` [� <br /> SIGNED TITLE� I j j�/I�� DATE r/ — <br /> S J A UI <br /> DEP RTMEN,T/J1/J SE ONLY <br /> Application Accepted By Date rT6 Area Employee IDN�. <br /> Grout Inspection By Dam_ ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth D <br /> COMMENTS �ti(s�_�'t�—!�/� <br /> PE SC Reed ved ►ec Amoont Date Permit/ Invoice N Well IDN <br /> Cede Into B u Rcdtted Service out N <br /> L4 b30 <br /> WELL PUW PERMIT <br /> END 43-01-006 <br />