Laserfiche WebLink
lri l W Jfw ('lyl 11v MINI <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS /�EEfXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 41" h 1�.. /2 //'(��-- CITY/ZIP k,05c�4 <br /> Of D <br /> CROSS STREET �-��"Si +Pry �28-LT,T�--•-Nif PARCEL SIZE�Q LAND USE APPLICATIONin <br /> OWNER NAME _ lJ�7` D� �� �O /� __._ PHONE .tea �// <br /> B7 . CITY/STATE/ZIP�1/Gl�/ �-l� L�' <br /> OWNER ADDRESS 2A <br /> CONTRACTOR 'w PHONE <br /> .y <br /> CONTRACTOR ADDRESS �d-,C�i1°1Gr;� CITYISTATEZJP <br /> SUSCONT A OR /` -/ ^4 [ry�-� PHONE �\ <br /> ACTOR ADDRESS � 1 � - �. /STAT&fl <br /> LICENSE -57 61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:[]General Mineral/Coliform Bacteria(4391)❑Dibromochioropropane(4392)❑Arsenic(4393) <br /> INTENDED USE omestic/Private ❑Irrigation/Agricultural rl Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> 1f different from Owner wa er System Name onName or Phone N=ber <br /> TYPE OF WORK IAOidew Well ❑Replacement Well ❑Well Alteration/Modification El Other <br /> ❑Monitoring Well(s) #of wells ❑SoilBoring(s) #otborigs ❑Geotechnical #orborings <br /> ❑Out-Of-Service Well (]Out-Of-Service Well Renewal ❑Cross-Connection Repair s ` <br /> ew Pump 0 Pump Replacement El Pump Repair []Raise Well Casing 'v <br /> WELL CONSTR T16N a <br /> Drilling Method <br /> ,,�Oud Rotary ❑Air Rotary (]Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth z7o_t ft Excavation /-Z in diameter ❑Open Bottom ravel Pack/Gravel Size in diameter <br /> ❑ConductXasing in diameter / Conductor Casing Depth I1 O <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad e-0 ❑Steel Wlastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth _� ft ❑Neat Cement(94 lb bag45-10 gal water) !❑Sand Cement sack mix/7 gal water <br /> [3OBentonite(20%solids) ❑Other <br /> Grout Placement Method JaPumped ❑Free Fall ❑Other ❑Retardant I Accelerator(name)____ <br /> PEDESTAL Installed By ❑Driller OumpContractor, ❑ Other <br /> ❑Concrete Pedestal ensions:Width ft Length ftThick in ❑Christy Box ❑Stove Pipe ' r <br /> PUMP ubmersible❑Turbine ('_]Other HP Pump Set It Standing Water Level --tt <br /> I HEREBY CERTIFY THAT I 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 p <br /> WORKERS COMPENSATION LAWS. <br /> MIN�I�Ai� % A�NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)95 -7697 l <br /> SIGNED 2 f��y//.J%r`'� TITLE n� — DATE - / <br /> J <br /> 1• L <br /> N J; x f. <br /> DE ARTM <br /> Application Accepted By� _ � Date <br /> ((I h � Area >rY/(��_/�*/ Employee ID#��F� <br /> Grout Inspection By_ ft Dale G '1 ❑ SPECIAL Well Permit <br /> Pump Inspection By Data 5 [gyp tf wy ❑ WAIVER Received <br /> Soil Boring Inspection By Dale Constructed Well Depth ft <br /> COMMENTS W 1;�41& 1/7-1 f 1;_i4i4 cr✓ C L4 D t NS n e-Gk,-rN <br /> PE Sc Received Check#I Amount Date Perm-V Invoice# Well ION <br /> Codes Into B Cash Remitted Service R uest# <br /> RUU 22-7 <br /> FIID 43-06 8/01/18 WELL(PUMP PERMIT <br />