Laserfiche WebLink
0 <br />c <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 - (209) 4683420 <br />N -REFUNDABLE PERMIT <br />ADDRESS �~ <br />SS STREET <br />IER NAME <br />IER ADDRESS 14 <br />ID <br />ADDRESS <br />CALL ZU9 yb34159/ FOR INSPECTIONS tAYIKtS l TEAR FROM DATE 155UEU <br />3uxuli V-- w` '` CrrYIZIP� <br />rte. APN(C& OA) - OZ PARCEL SIZ6,-�Q LAND USE APPLICATION # <br />VAPCIL &S PHONE — Q <br />I 7 <br />1- C a} V- CITY/STATE/ZIwclad-)o <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE �: C-57 C-61 C D-09 Other <br />CITYISTATEIZIP <br />PHONE <br />CITY/STATE/ZIP- <br />NUMBER E%PIRATION <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />!TENDED USE i Domestic/Private X Irrigation/Agricultural L Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />C Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />YPE OF WORK f- New Well _Replacement Well I- Well Alteration/Modification Cherto <br />= Monitoring Well(s) # of wells C Soil Boring(s) a of borings - Geotechnical a of borings <br />f(,Qac f Out -Of -Service Well C Out -Of -Service Well Renewal= -Connection Repair <br />C New Pum '-Pum Replacement C Pum Repairise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method C Mud Rotary F Air Rotary C Auger C Cable Tool Push Point - Other <br />Proposed Well Depth ft Excavation in diameter C Open Bottom - Gravel Pack/Gravel Size in diameter <br />C Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched C Steel - Plastic Stainless Steel C Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) = Sand Cement sack mix77 gal water <br />Bentonite (20% solids) ❑ Other <br />Grout Placement Method Pumped ` Free Fall C Other C Retardant / Accelerator (name) <br />PEDESTAL Installed By L Driller ❑ Pump Contractor C Other <br />Concrete Pedestal !-Dimensions: Width ft Length It Thick in L Christy Box L Stove Pipe <br />PUMP SubmersibleC Turbine D Other HP Pump Set ft Standing Water Level It <br />10 <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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />llWri"�►1fi�����I� ' � <br />EHD43-06 8/0V16 WELL/PUMP PERMIT <br />r <br />Y <br />EIL R T M E N T USE O q•LY <br />Application Accepted ByMml <br />Date I�1U17 <br />Area Employee ID# <br />Grout Inspection By <br />Gro p <br />Date 1W211 <br />Permit <br />Pump Inspection By <br />Date j % <br />WAIVER Received <br />Soil Boring InJ�pection By <br />Date <br />Constructed Well Depth <br />ft <br />COMMENTS 156�'I 4 <br />G / <br />llWri"�►1fi�����I� ' � <br />EHD43-06 8/0V16 WELL/PUMP PERMIT <br />r <br />Y <br />