Laserfiche WebLink
•1 Y <br />WELL/PUMP PERMIT <br />SAIFJOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT L t;ALL LUy UO3-tb9t FOR INSPECTIONS /t-APIKt5 1 YEAR FROM UATE ISSUED <br />JOB ADDRESS ��/Va 1/�l' h / / CITY/ZIP L<G� �/i / V�� t�•S l/L� <br />CROSS STREET 1-6j w) tcg L412 t L/ APN 164 u 41/1 PARCEL SIZE , LAND USE APPLICATION # <br />OWNER NAME <br />C-1 PHONE <br />OWNER ADDRESS H5 CITY/STATE/ZIP <br />CONTRACTORPHONE AdeI �G- �2 --3�X <br />CONTRACTOR ADDRESS JCA lw,Wlpldtt, "v CITY/STATE/ZIP L GCS, L%. .7 ICL <br />SUBCONTRACTOR IT4 PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE FOC -57 ❑ C-61 ❑ D-09 ❑ Other <br />NUMBER <br />CITY/STATE/ZIP <br />EXPIRATION DATE S �- <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ®Soil Sampling/Characterization <br />❑ Public Water System <br />If diffe, ent from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ 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 ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />LJ Ivew rump L i rump meplacemem L i rump mepalr Li raise vveu uasing <br />WELL CONSTRUCTION <br />Drilling Method [54Mud Rotary ❑Air Rotary WAuger ❑Cable Tool E] Push Point ❑ Other <br />Proposed Well Depth %S - .51 ft Excavation &) -A in diameter E] Open Bottom ❑Gravel Pack/Gravel Size <br />❑ Conductor Casing __ _ ----in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />in diameter <br />Grout Seal Depth ft ;Oeat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Benton ite (20% solids) ❑Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />E] Concrete Pedestal dimensions: 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 COMPENSATION LAWS. <br />MI M 24 HQU ,A9CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED u��� TITLE��- telln't4! �/ �" ©hG T EWE P- Full <br />�® T <br />T <br />m <br />D <br />0 <br />0 <br />m <br />m <br />N <br />Application Accepted By <br />IDE ARTMENT S ONLY <br />Date7 <br />Area �LWEmployee ID# <br />bw <br />Grout Inspection By <br />/ Date qz <br />SPECIAL Well Permit <br />Pump Inspection By <br />Date <br />❑ WAIVER Received <br />Soil Boring Inspection By <br />Date <br />Constructed i'veii Depth <br />ft <br />COMMENTS <br />L' <br />fir °) di tr31 <br />PE SC Received Check#/ Amount <br />Codes Info B Cash emitted Date <br />Permit/ <br />Service Request # Invoice # Well ID# <br />//t(* <br />d 37-)Z <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />