Laserfiche WebLink
JAJ2 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> WN-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS / �/J/G�tJ(/ LSC CITY/ZIP <br /> m <br /> CROSS STREET `LV V-0— K<j APN 7— 6920 PARCEL SIZE �Q� LAND USE APPLICATION v <br /> OWNER NAME PHONE <br /> OWNER ADDRESS ,01 V CITY/STATE/ZIP r-no V! I <br /> CONTRACTOR M4, ' L/M.S y (n 1 { 1 fi(l) PHONE <br /> CONTRACTOR ADDRESS 117 9/evlas l CITY/STATE/ZIP_ Q��S�r 4 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP /� p <br /> LICENSE 46-57 El C-61 [I D-09 ❑Other NUMBER 7 ? EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:(General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE I gDomestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring [:]Soil Sampling/Characterization <br /> ❑ ublic Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK 'Aew Well ❑Replacement Well ❑Well Alteration/Modification El Other <br /> ❑Monitoring Well(s) #of wells [:]Soil Boring(s) #of borings #of borings <br /> [:]Geotechnical <br /> F-1 Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pum ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑Air Rotary ❑Auger El Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth4l-2ft Excavation ,lZ in diameter E]Open Bottom ravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ©O El Steel I>Itlastic F]Stainless Steel ❑Other <br /> Grout Seal Depth Lj&17 10�ft ❑Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> Hite(20%solids) ❑Other <br /> Grout Placement Method KPumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller X113ump Contractor ❑ Other <br /> [j Concrete Pedestal me sions: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 Rt-GULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAI' I Aryl IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANPE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> r:• � J j <br /> SIGNED TITLE � DATE <br /> jr MEN <br /> 11 Ir I COUl in <br /> MA <br /> T O P <br /> Dll ARTMENT U E ONLY <br /> Application Accepted By ` Date Area Employee ID# =GC�1 <br /> Grout Inspectiol5-B . Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS We!( ✓ i ��'Q s/✓/ e <br /> PE SC Received heck!/ Amount Date Permit/ Invoice# Well ID# <br /> Codes r1ofo RemittedSeryice Re qqeq # <br /> 19 IMP 04TW <br /> lb(91 al <br /> Zi 9 V i7 1: <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />