Laserfiche WebLink
WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT J CALL(209 9) 53-7697 FOR INSPECTIONS EXPIRES 1 YEAR <br /> FROM DATEE�ISSUED <br /> ft9ADDRE33 jI, � f ! - -A" CITYIZIP <br /> CROSS STREET fEf1JISl� APN_/2Z—2j O"af PARCEL SIZE 130,01 <br /> OWNER NAME P�HOyN�E gal <br /> OWNER ADDRESS S CITYWATE/ZIP 13 C! { s 64 • .Q,�� <br /> CONTRACTOR JG/I� `F� /yL/�G��O �y� 1� PHONESO <br /> CONTRACTORA6D,RESS_(� � CMISTATFIZIP SL 7B <br /> SUBCONTRACTOR) e PHONE <br /> SUBCONTRACTOR ADDRE.3S /00 RA [ CITY/STATE/ZIP <br /> LICENSE -57 ❑C-61 ❑D-09 ❑Other NUMBER t EXPIRATION DATE a <br /> GEOGRAPHICAL JNFORMATION7 Coordinates X J�4c Township Range Section <br /> INTENDED USE ZKDomestic/Private Q Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water 5yst C,fYrC /1'� L <br /> Vdifferent from Owner ever Rem NPIME Caract Nameor Fliew Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other <br /> .+ KMonitoring Well(sftV aumberof wens ❑Soil Boring(s) number of bonno ❑GWteehniCal number orboriolp <br /> ❑Well Destruction ❑Out-Of-Service We]1 ❑Out-Of-Service Well Renewal <br /> O New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair <br /> WELL CONSTRUCnON <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 Sizc in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Coming Diameter _Z_,an Thickness/Gaugp PASTM Sched 4- ❑Steel Itplastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth 67^2� fi AkNeat Cerriont(94/h lag 15-I0 gal water) ❑Sand Cement sack mix 17 gal water <br /> S-'* , JM!Ibrttonite(20%solids) ❑Manufacturer Spec%solids % Name _ ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped /Free Fall ❑Oth-r ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed B )VDriller ❑Pump Contractor ❑Other <br /> 44Sroncrete Pedestal Dimensions: Width ft Length ft 'rhick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set R Standing Water Level It <br /> WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other <br /> Well Diameter in Total Depth fl Dcpth to Water 11 ❑Casing to be Perforated from II to R <br /> Sesung Moterlal ElNcat Cement(941b bag/5-10gal water) ❑Sand Cement sack mix 17 gal water ❑Bentonite Pellets <br /> ❑Bentonite(20a/o solids) ❑Manufacturer Spec%solids__.—% Name ❑Specs on File ❑Specs Submitted <br /> Placement Method ❑Pumped ❑Free Fall ❑Other <br /> ❑Complete with Mushroom Cap ft below grade ❑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 /> WORKERS COMPENSATION LAWS. <br /> MINI UM 24 14OUR ADVANCE NOTICE REQU11RI D FOR INSPECTIONS <br /> 51GNED TTnE G DATE <br /> 44 <br /> rg R i <br /> 5 _ q- E <br /> � P - <br /> � � iz <br /> R <br /> Z <br /> O4491 <br /> w <br /> s a <br /> U <br /> I r Ica <br /> Application Accepted By Date 0 Areal Employee IDN <br /> r-- Growl{ne�oc`'' n dyi[m Date ❑ SPECIAL Well Pet-mit <br /> Pump[ns�eclir Date ❑ WAIVER Received <br /> Destruction Inspection By Dote Constructed Well Depth <br /> COMMENTS_ <br /> PE sic Amount Received Date Permit)Codes Info Remitted ash By Service Request# Invoice A[ well IDrV <br /> EHD 43-02-006 i MASTER WATER WELL PERMIT <br /> 51712002 TnspPc�" uPs-F A��• �-�• -# �r7 - 7b9 <br />