Laserfiche WebLink
i WELL/PUMP PERMIT <br />P� <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE,QERM�,T f I CALL (209) 953-7697 FOR INSPECTIONS nt EXPIJRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS <br />CROSS STREET <br />iANER NAME <br />CiNNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACnbR ADDRESS <br />/�1 l Lir V\ k L- L- l CITY/ZI ) 1 <br />� <br />l t7J �� PARCEL SIZE LAND USE APPLICATION <br />LICENSE IQC-57❑ C-61 ❑ D-09 ❑ Other Nu <br />CITY/STATE/ZIP 1 <br />Sc Received eck Amount D to Permit/ Invoice # Well ID# <br />Info Bash Remitted Service Request # <br />PHONE <br />CITY/STATE/ZIP <br />PHONE <br />CI E/ZIIPP <br />i <br />WY/STAT)i / <br />EXPIRATION DATE <br />DOMESTIC WELL $ MPLING: ❑General Mineral/Coliform Bacteria (4391) LJDibromochloropropane (4392) LjArsenic (4393) <br />INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial E] Water Quality Monitoring ❑Soil Sampling/Characterization <br />❑ ublic Water System <br />If different from Owner: Water System Name L;ontact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well [-]Well Alteration/Modification L] Other <br />El Monitoring Well(s) # of wells E] Soil Boring # of borings s) ❑Geotechnical # of borings <br />❑Out-Of-Serviceell ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />E]New Pump Pump Replacement ❑ Pump Repair E]Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method E] Mud Rotary E-] Air Rotary ❑Auger ❑Cable Tool E] Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter E] Open Bottom []Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel [-]Other <br />Grout Seal Depth ft ❑ Neat Cement (94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) [:]Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />[LConcrete Pedestal EPimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP N Submersible❑Turbine ❑Other HP _'J Pump Set ft Standing Water Level ft <br />I HEREBY CE I 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 />MINIMUM 24 I%�NOTICE REQUIRED FQR INS E�}jCj�T�IO�NS - PLEASE CALL (209))j 3- 7 <br />SIGNED ��RWVANCE <br />X�(/r ��( t ) TITLJ rb-4M � DATE `�1, <br />DEPARTMENT USE ONLY <br />Application Accepted By, Date <br />Grout Inspection By Date <br />Pump Inspection By 1 Date <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Area (A C Employee ID# <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />T <br />PE <br />Codes <br />Sc Received eck Amount D to Permit/ Invoice # Well ID# <br />Info Bash Remitted Service Request # <br />l <br />DSO t,0 <br />EHD 43-06 6/01/16 WELL /PUMP PERMIT <br />