Laserfiche WebLink
WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTou AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />IN VIV-Rtt U NUACLt rtHmii ` /UALL�JZUy Ub:i-lbblI FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUE[ <br />JOBADDRES$ �DOIyS �GQfJ(II�FIAIG Kn �FRONI IJF IT�iOPC�j�/ CITYIZIP �ryGJ� <br />CROSS STREET W. //F� RNT L /it/E 1217 _ APN f2alA>'� IAa'6G "X PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME ]�)LJ jU,gauiAj l'nr/AJ'iry PHONE <br />ADDRESS <br />CITYISTATEIZIP <br />CONTRACTOR -,;A Ae!f' ��,n.o�/, f 6*9PHONE kY&' <br />CONTRACTOR ADDRESS (�!1 LALY_ CITY/STATEIZIP /f/>rYW H1i LJ ).+-l7 <br />AWMONTRACTOR CASGROF_ C//[i`1�//�%l9 PHONE p 109 - —r jI - HUIy <br />NTRACTOR ADDRESS J S66 g)212UW I I W V CITY�/SSTATE/ZIP MOAXGLAIIZ iGA- T'I I �74 3 <br />LICENSE /( C-57 D C-61 D D-09 0 Other NUMBER 3 D I I EXPIRATION DATE _I / _jW 1 7 <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) _ Dibromochloropropane (4392) _ Arsenic (4393) <br />INTENDED USE 0 Domestic/Private 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring ❑ Soil Sampling/Characterization <br />0 Public Water System <br />If dit(erenl from Owner. Water System Name Contact Name or Phone Number <br />TYPE OF WORK *K New Well 0 Replacement Well ❑ Well Alteration/Modification X OtherL1111'140 jr- <br />❑MonitoringWell(s) #of wells 0 Soil Boring(s) Nofborings ❑Geotechnical #or borings <br />0 Out -Of -Service Well D Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />0 New Pump 0 Pump Replacement D Pump Repair 0 Raise Well Casino <br />Drilling Method '}t Mud Rotary ❑ Air Rotary ❑ Auger 0 Cable Tool 0 Push Point ❑ Other <br />Proposed Well Depth :bU, ft Excavation � in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />0 Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing DiameterIckness/Gauge/ASTM Sched ❑ Steel ❑ Plastic 0 Stainless Steel 0 Other <br />Grout Seal Depth t '% Neal Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />0 Ben.nile (20% solids) 0 Other <br />Grout Placement Method )( Pumped 0 Free Fall 0 Other ❑ Retardant /Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br />0 Concrete Pedestal ODImensions: Width ft Length ft Thick in Christy Box 0 Stove Plpe <br />PUMP 0 SubmersibleD Turbine 0 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 COMPENSATION LAWS. <br />MINIMUM 24 HOUR ADVAN E OTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-77/697 <br />SIGNED /i �� TITLE V/ 5'0 IC DATE <br />DEP RTMENT SE 0 N6 Y <br />Application Accepted Byf"fiRRDale 10 1 <br />Grout Inspection Byit, Dale <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />AV <br />1/ <br />ti nr�Rq �Ily co <br />�(� � �tTy� pqR �u� �, <br />Area c -,I �l q Employee ID#_M� % <br />—❑ SPECIAL—Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth K <br />I / nn L,i .r/ r ivi_ <br />Mc <br />�.3►4IJ�Id�/:'J� /l�Li����i�f11111I�Ji��� ►iii .'��"�� <br />EHD43-06 8,1101/16 wELL,PUKIP PERMIT <br />