Laserfiche WebLink
Sr _ r WELL/PUMP PERMIT P ✓ 9 <br />0A JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />UALL <br />LUy 1153 -/by FUK IN5Ptc I IUNS <br />t=Ar imca I T tAK I-KUM UA I t IJJUtu <br />1.6 �7 10 <br />AocljCITY/ZIP <br />JOB ADDRESS <br />9 1Ole, itty <br />L <br />CROSS STREET <br />1� (JV it <br />APN JQ <br />— <br />i _ �TPARCEL SIZE3I • I <br />LAND USE APPLICATION # <br />_ <br />OWNER NAME <br />1 1� <br />(� l <br />-rt� <br />PHONE <br />? <br />JAM— — <br />" <br />OWNER ADDRESS <br />\ /� !�f-� <br />V l) f� l <br />/'1.' /'� !✓ °Y CITY/STATE/ZIP <br />CONTRACTOR <br />�Z3C f-'­w11 <br />rM <br />' <br />CITY/STATE/ZIP <br />✓ <br />Ca`� I <br />�L'N' ✓ <br />CONTRACTOR ADDRESS <br />�V <br />/I 1 <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />CITY/STATE/ZIP <br />LICENSE IJ C-57 <br />❑ C-61 [ID -09 <br />❑Other <br />1 <br />NUMBER <br />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 ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different 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 I I Soil Boring(s) # of borings LI Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br /># of borings <br />El New Pump Pump Replacement u Pump Kepalr ❑ Kaise vveii i,asing <br />WELL CONSTRUCTION <br />Drilling Method ❑ d Rotary ❑ Air Rotary ❑ Auger ❑ able Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter I Open Bottom I Gravel Pack/Gravel Size_ <br />❑ <br />Co <br />r Casing in diameter / Con uctor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched I l Steel ❑ Plastic ❑ ainless Steel ❑ Other <br />Grout Seal Depth ft I I Neat Cement (94 Ib bag/5- gal water) ❑ Sand Cement & <br />in diameter <br />mix/7 gal water <br />❑ Bentonite (20% s 'ds) ❑ Other <br />Grout Placement Method ❑ Pumped Li Free Fall ❑ Other Il Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in [I Christy Box 7 Stove Pipe <br />PUMP ❑ Submersibl .., Turbine ❑ Other HP _YO 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 />WORKER OMPENSATION LAWS. <br />14111141111AUM 241HQlaIR1ADYAN�E-NOTIC,E REQUIRED FOFAINSPECTIOINS - PLEASE CALL (209) 9 3-7f;97 <br />SIGNED <br />P T M E N T SE NLY <br />Application Accepted By Date l� <br />Grout Inspection By Date <br />Pump Inspection by i. DaF� CT <br />Soil Boring Inspgction.By Date <br />COMMENTS QX�1 D �L�L �� r^� D &I- (L+ S <br />14,11 DATE <br />Area Employee ID#� <br />❑ SPEC AL Well Permit <br />❑ WAIVER Received <br />Constquctgd Well Depth ft <br />W <br />PE SC Received Check#/ Amount <br />C d s Info B Cash emitted <br />Permit) <br />Date ServiceRe uest # <br />Invoice # Well iD# <br />1.6 �7 10 <br />IF <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />