WP0038332 - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMIT I19�✓ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT, / CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE IIS/SUED JOB ADDRESS 5a 4 U 4yq L ! —q �%PA cl 'j Cm21P �/ 'x" !:2:4 C' k "t S 5 a CROSS STREET R E- ++s s i e- k t�/P.i t A,P/N G 7 7 -/G / C) — Z /S- PARCEL SIZE LAND USE AAPPLICATION #7 n ^7 c� p OWNER NAME DC7 /P ©IV U1 /4 o (U A K ,C I C / o � OIL �«'l t-/ X U PHONE CEO O 'C- X7(8 L !. OWNER ADDRESS ZP'I1 o/)1CJA �W44 CRY/STATE/ZIP ?--h e CL1 CONTRACTOR I'-�I I I Sl d e T'7 I I l 1� l PHONE -Z qq 8 t J Sq4 U CONTRACTOR ADDRESS Pic, -30K 43 CRY/STATE/ZIP_-T- ck G SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CRY/STATE/ZIP%% /1 a LICENSE kl C-57 n C-61 n D-09 F Other NUMBER d (� 2 7V EXPIRATION DATE G 1 DOMESTIC WELL SAMPLING: n General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane (4392) n Arsenic (4393) INTENDED USE n Domestic/Private n Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ill Sampling/Characterization F1 Public Water System If different from Owner. Water System Name Contact Name or Phone Number TYPE OF WORK n New Well n Replacement Well n Well Alteration/Modification Fl Other n Monitoring Well(s) # of wells ❑ Soil Boring(s) #of borings Geotechnical 0 o borings F1 Out -Of -Service Well n Out -Of -Service Well Renewal n Cross -Connection Repair ❑ Kass Drilling Method n Mud Rotary n Air Rotary K Auger n Cable Tool n Push Point n Other Proposed Well Depth 40 It Excavation (Q_ in diameter ❑ Open Bottom n Gravel Pack/Gravel Size in diameter FI Conductor Casing &_ in diameter / Conductor Casing Depth ft Well Casing Diameter _ in Thickness/Gauge/ASTM Schad n Steel n Plastic n Stainless Steel n Other Grout Seal Depth/-" Oft j1 Neat Cement (94 Ib bag15-10 gal water) n Sand Cement sack mix/7 gal water n Bentonite (20% solids) n Other Grout Placement Method Fl Pumped 76 Free Fall n Other s Retardant / Accelerator (name) PEDESTAL Installed By FI Driller n Pump Contractor n Other s Concrete Pedestal FIDlmenslons: Width ft Length It Thick in n Christy Box Il Stove Pipe PUMP n Submersibles Turbine n Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATIODiEAWS. MIND IGf 48 H UR NCE NOTICE REQUIRED FOR INSPECTIONS - P EASE CALL (209) 953-7697 SIGNED _ TITLE Se 1'5 S � �9u DATE S—/z !r =FIVE® 25 2018 COUNTY ak;� dDP , MENT U`Y Application Accepted By Date Area ��/�J%Employee ID#Q`��"'- Grout Inspection By Date fl PECIAL Well Permit Pump Inspection Bygyp, F1 WAIVER Received Soil Boring Inspection By !tr►6 ltr "0-4V--JDDate ate F Constructed Well Depth ft COMMENTS M0M=U=,70' M W- "l, 7, 7,11111111 Peri r EHD 4306 revised 4/14118 WELL /PUMP PERMIT