Laserfiche WebLink
WELL/PUMP PERMIT 40, J<✓ t <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT GALL ZUy yb3-/6y / FOR INSPECTIUN5 cArimca I r tAK I-KUm vA I t Iaautu <br />_R2rj Cf <br />JOB ADDRESS ` CITY/ZIP <br />CROSS STREET I —) A 2 S 0 J U PARCEL SIZE' _/• 2- LAND USE APPLICATION # <br />OWNER NAME PHONE <br />OWNER ADDRESS OEM 1 CITY/STATE/ZIP <br />W104P ' q .L <br />CONTRACTOR PHONE <br />CONTRACTOR ADDRESS .� CITY/STATE/ZIP <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE Y"6-57 ❑ C-61 ❑ D-09 1 Other NUMBER 4WD CI I U EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring n Soil Sampling/Characterization <br />Fl Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK <br />❑ New Well ❑ Replacement Well F I Well Alteration/Modification ❑ Other <br />Amount Date <br />Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />❑ Monitoring Well(s) # of wells Fl Soil Boring(s) # of borings ❑ Geotechnical <br /># of borings <br />77 <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal LI Cross -Connection Repair <br />PA <br />CI New Pum ❑ Pump Replacement )(Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method <br />❑ Mud Rotary ❑ Air Rotary ❑ Auger LI Cable Tool ❑ Push Point ❑ Other <br />dbp <br />Proposed Well <br />Depth ft Excavation in diameter Cl Open Bottom ❑ Gravel Pack/Grave4Size' IT meter <br />iV <br />`��.EWWIlV�►?��0�A^WI <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />/N COV <br />Well Casing <br />Diameter _ in Thickness/Gauge/ASTM Sched Li Steel 11 Plastic Fl Stainless Stet <br />q��N18�1 <br />Grout Seal <br />Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement <br />UU%gal water <br />NT <br />❑ Bentonite (20% solids) 11 Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall Cl Other 11 Retardant /Accelerator (name) <br />PEDESTAL <br />Installed By ❑ Driller ❑ Pump Contractor 11 Other <br />I Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP <br />F ubmersible❑ Turbine I I 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 />F <br />MINWIMIN 24 HOORADVANCE NOTICE REQUIRED FOR-WSPECTIQNS - PLEASE CALL (209) 953-76P7 <br />�EPARTMENT USE ONLY <br />Application Accepted By Date <br />Grout Inspection By Date <br />Pump Inspection By Date Z� <br />Soil Boring Inspection By Date <br />COMMENTS <br />Ln <br />A <br />m <br />D <br />0 <br />0 <br />X <br />M <br />U) <br />V) <br />Area S '/) G% Employee ID# A h m, d <br />Ll SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC Received C <br />Info ash <br />Amount Date <br />Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />416-10 <br />S u <br />77 <br />WM3 31109 <br />-IV15 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />