WP0037925 - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMIT 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 ISSUED JOB ADDRESS s- I�!fir e r IzJ CITY/ZIP 2i►�u^ (_ 't /i J m t �} (/ D CROSS STREET 111y e r 1-Lo4 APN 2-45- Zl o - ZI PARCEL SIZE 1`J4 LAND USE APPLICATION# o y F -7q,39 X OWNER NAME j� i A 2-0 A f" I Wt(rS PHONE ✓/y' 'j N OWNER ADDRESS P•C�. �i 1 ( 5 CITY/STATE/ZIP �1 Pa 1-4 /JJ CONTRACTORAlbers I WA.4 �� /PHONE CONTRACTOR ADDRESS_ ' 1 CITY/STATE/ZIP / � �O� Je l �i U-?C /7 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 El C-61 El D-09 0 Other NUMBER ra EXPIRATION DATE �7 j G- -7 DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE ❑Domestic/Private rrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings E]Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection Repair ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing WELL CONSTRUCTION Drilling Method'(Vlud Rotary ❑Air Rotary ❑Auger ❑9ble Tool ❑Push Point ❑ Other Proposed Well Depth 4 0 ft Excavation -5 in diameter E]Open Bottom NGravel Pack/Gravel Size in diameter F]Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter 12- in Thickness/Gauge/ASTM Sched -2-4>0 ❑Steel -NPlastic El Stainless Steel [-]Other Grout Seal Depth-5n ft ❑Neat Cement(94 Ib bag/5-10 gal water) NSand Cement sack mix/7 gal water ❑Bentonite(20%solids) ❑Other Grout Placement Method Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other ❑Concrete Pedestal dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible❑Turbine ❑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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I APA IN romPL!ANCE. WITH ALL WORKERS COMPENSATION LAWS. MI"UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED TITLE ` '"' DATE % t L" -7 S '0 Yl 1' 'A r ' ^ r N .3 h DEPARTMENT USE ONLY 4� Application Accepted By �— Date /41h Area 7 Employee ID# Grout Inspection By 1 Date ❑ SPECIAL Well Permit Pump Inspection By ✓- 7Z Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info By Cash emitted Service Request# 3& 3-'-t) 7 f O-7-1 V((V 25 EHD 43-06 8/01/16 WELL/PUMP PERMIT