Laserfiche WebLink
WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)469-3420 <br /> NON-REFUNDABLE PERMIT <br /> CALL(209) <br /> CALL209 jL 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS /t� l/LJ Q'1 ,I l Lt(%l/ti A"'> O '� <br /> CITYIZIP '1` 1 C7^J 5�] 9b <br /> /}a A 0 <br /> CRO53 STREET C.. kgoc-i t7`� I lE)t APN_ q',- Z 7' ;J PARCEL SREy(,;1 y LA.USE APPLIC)A71ON# <br /> OWNER NAME jI/10A4A k)I% /L��y�,�C!��ra�+11 PH. ], <br /> OWNER ADDRESS n Tt )p Ing,S—, 11 p oz1\ <br /> tj . ,"Ya,1 CRYISTATE/ZIP�1 i,.— )_'j S4 (Ps Al o,6 <br /> CONTRACTOR LIZ ♦�I �fa�J 11 —,C)a I L LL r n,l PHONE -Ici� J-71-q 5 " <br /> CONTRACTOR ADDRESS .S�l� IL1r-�� !tr'lQ 1> CRYISTATEMP I�7 I/J 1'/97 019 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CRYISTATTEIZIP <br /> LICENSE 7 C-57 C-61 _ D-09 _Other NUMBER b 7 EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Rang@ Section_ <br /> r <br /> D USE Domestic/Private - Irrigation/Agricultural -_Industrial Water Quality Monitoring -,Soil Sampling/Characterization <br /> Public Water System <br /> If different h°m Owner: Water byStern Narne or <br /> TYPE OF WORK New Well Replacement Well ,KWellAlterationlModification :Otherl&Atik ill "Wluii '�►ul�� <br /> MonitoringWell(s) #of wells SoilBoring(s) #OfhOn,,ge Geotechnical sOfbO°°� <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casco <br /> WELL CONSTRUCTION <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(941b bag/5.10 gal water) - Sand Cement sack mixl7 gal water <br /> Bentonite(20%solids) --Other <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 " "r —ft <br /> I HERE ITH SAN <br /> JOAOU NSE IS <br /> CURRE p ^^ D ' > �yNy /_/�` ITH ALL <br /> WORKS ✓1/� /, ) I C GAO J y � ,/^`k I <br /> $NUVED, <br /> DEPARTMENT USE ONLY <br /> Application Accepted By '— — _ Date 2.11 Area Employee ID# <br /> Grout Inspection By _ Date f11 <br /> Z IC SPECIAL WBII PCT11 <br /> Pump Inspection By Date � WAIVER REC2IVEd <br /> MM <br /> Soil Boring tion By Date_ Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permi Invoice# Well ID# <br /> Codes Info By_ Cash Remitted Service Request# <br /> .�q13 313 L.SSI S-0 � 2 } ;M w 1 <br /> : 113 313 w <br /> -2Cif T 3i 3 IV W721,7-- <br /> E111111-0. <br /> _EHD13.00 WELL/PUMP PERMIT <br /> 1/30/12 <br />