WP0038230 - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMIT P '� r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NON-REFUNDABLE PERMIT JOB ADDRESS CROSS STREET i OWNER NAME OWNER ADDRESS ^? CONTRACTOR I CONTRACTOR ADDRESS SUBCONTRACTOR SUBCONTRACTOR ADDRESS LICENSE ❑ C-57 ❑ C-61 ❑ D-09 n Other ` GALL (1Uy) 95;i- 6U1 FOR INSPECTIONS t7%1'IKtb 'I YEAR FROM UATE ISSUED QA CITY/ZIP n PN Q 74-K' /D> /�P�A�R)CELSISIZE 5 • L LAND USE APPrLICCAATfION[#�/'� r •� i l yin ' A 1LI C�IC- Ff�I � PHON ?""" DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) If NTENDED USE - Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial [I Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK U New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells U Soil Boring(s) # of borings U Geotechnical # of borings ❑ Out-Of-Service�W�II ❑Out Of -Service Well Renewal 11Cross-Connection Repair U New Pump Q(Pump Replacement n Pump Repair ❑ Raise Well Casing Drilling Method U Mud Rotary ❑ Air Rotary Ll Auger ❑ Cable Tool I I Push Point U Other Proposed Well Depth ft Excavation in diameter I I Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched U Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft n Neat Cement (94 Ib bag/5-10 gal water) [I Sand Cement sack mix/7 gal water U Bentonite (20% solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other I I Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in U Christy Box ❑ Stove Pipe PUMP )(Submersible[] Turbine I1 Other HP Pump Set ft Standing Water Level ft I HEREBY CERT FY 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 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINI M 24 H D%VANCE NOTICE REQUIRED FOR I SPECTIO S - PLEASE CALL (209) 9(53-7697 SIGNED LF` TITLE L/e� % DATE Application Accepted By Grout Inspection By Pump Inspection By Soil Boring Inspection By COMMENTS EPARTMENT U Date Date Date l'1 Date Area Employee ID# N ❑ PECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft ;r m D v 0 rn U) ch PE Codes SC Received (CheckK Amount Permit/ Info B ash Remitted Dae Service Request # Invoice # Well ID# .M q 0 CITY/STATE/ZIP 1 PHONE 12� 1 CITY/STATE/ZIP � PHONE CIY/STATE/ZIP NUMBER \ 0 EXPIRATION DATE DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) If NTENDED USE - Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial [I Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK U New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells U Soil Boring(s) # of borings U Geotechnical # of borings ❑ Out-Of-Service�W�II ❑Out Of -Service Well Renewal 11Cross-Connection Repair U New Pump Q(Pump Replacement n Pump Repair ❑ Raise Well Casing Drilling Method U Mud Rotary ❑ Air Rotary Ll Auger ❑ Cable Tool I I Push Point U Other Proposed Well Depth ft Excavation in diameter I I Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched U Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft n Neat Cement (94 Ib bag/5-10 gal water) [I Sand Cement sack mix/7 gal water U Bentonite (20% solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other I I Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions: Width ft Length ft Thick in U Christy Box ❑ Stove Pipe PUMP )(Submersible[] Turbine I1 Other HP Pump Set ft Standing Water Level ft I HEREBY CERT FY 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 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINI M 24 H D%VANCE NOTICE REQUIRED FOR I SPECTIO S - PLEASE CALL (209) 9(53-7697 SIGNED LF` TITLE L/e� % DATE Application Accepted By Grout Inspection By Pump Inspection By Soil Boring Inspection By COMMENTS EPARTMENT U Date Date Date l'1 Date Area Employee ID# N ❑ PECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft ;r m D v 0 rn U) ch PE Codes SC Received (CheckK Amount Permit/ Info B ash Remitted Dae Service Request # Invoice # Well ID# .M q 0 EHD 43-06 8/01/16 WELL /PUMP PERMIT