Laserfiche WebLink
WELL/PUMP <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />1010L`IIL/:111111Z1►1_1.34VilII hG111111114 <br />JOB ADDRESS <br />CROSS STREETW40�� 'APN <br />T` <br />OWNER NAME 0,V I�r I V-\ I Cil t/( <br />7--�-t`1 D% --N i F/ <br />PERMIT <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />1 y53 -/(i9/ FOR INSPECTIONS EXPI/�KE5 9 YEAR FROM DATE ISSUED <br />FAJ CITY/ZIP (��c t4ort gSoZ % a <br />—o7yo 7 <br />�PARCEL SIZE'LAND USE APPLICATION # <br />OWNER ADDRESS 3 �C1� 3 M� 0,/js`S ► M13 G 1 <br />CONTRACTOR WL J I r�O&,% ff <br />CONTRACTOR ADDRESS 1 . V <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE -57 ❑ C-61 <br />❑ D-09 ❑ Other <br />PHONE 2X9 — 99)l-8C)9p,_ <br />CITY/STATE/ZIP S-iocXv C14 9sa la <br />PHONE/ ZpCJ/ 7 Yj� /SLt( <br />CITY/STATE/ZIP L�t �a n (� g S3 as <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER V /q / 6 L EXPIRATION DATE <br />DOMESTIC WELL SAMPjkING: LJGeneral Mineral/Coliform Bacteria (4391) LlDibromochloropropane (4392) LArsenic (4393) <br />INTENDED USE [Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water 6ystem Name Contact Name or Phone Number <br />TYPE OF WORK SKewWell ❑ Replacement Well ❑ Well Alteration/Modification ❑Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑Out -Of -Service Well E] Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />New Hum <br />NUM <br />Raise vveii <br />WELL CONSTRUCTION <br />Drilling Method V<d Rotary El Air Rotary ❑Auger ❑Cable Tool E] Push Point ❑ Other <br />Proposed Well Depth alio ft Excavation z'A in diameter El Open Bottom Rdravel Pack/Gravel Size in diameter <br />F-1 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter In Thickness/Gauge/ASTM Sched Zoo []Steel la ❑Stainless Steel E] Other <br />Grout Seal Depth ) )% ft ❑ Neat Cement (94 lb bag/5-10 gal water) and Cement 1 1 S J S1aLc"k` ;,ix/7 gal water <br />❑ Bentonite (20°o solids) ❑ Other IU • , ALL <br />Grout Placement Method umped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller dump Contractor ❑ Other <br />F-1 Concrete Pedestal Fpimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP ❑ Submersible ❑Turbine []Other HP Pump Set ft Standing Water Level ft <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 <br />WORKERS COMPENSATIOUJ_.AWS. . <br />T <br />1 <br />m <br />v <br />0 <br />rn <br />m <br />er <br />Cn <br />E P R T M E N T U.S E ONLY �( } <br />Application Accepted B Date Area Employee I D# jn <br />Grout Inspection _ Date ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth l ft <br />COMMENTS Z&I ST/A,bi/V 5 � (C— IIS M%�LL— I S � ZJ1It� L�/ViT L �� <br />PE Sc Received <br />Codes Info B <br />Check#/ <br />Cash <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />�" <br />Ar <br />LI <br />y <br />Q <br />" .c. -1"I7 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />