Laserfiche WebLink
1, <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />-7175 U 14 ed <br />JOB ADDRESS CITY/ZIP v <br />CROSS STREET' OIA APN (•'1� �' PARCEL SIZELAND USE APPLICATION # <br />c <br />OWNER NAME 01117 WaC )0 PHONE Ui �✓ <br />OWNER ADDRESS CITY/STATE/ZIP /��/� <br />CONTRACTOR �% /� / I �I �% /� N12D qL % Fj�� <br />CONTRACTOR ADDRESS 2-1, !/! / / /l� J �J, CITY/STATE/ZIP l ��� r-/ ✓ <br />SUBCONTRACTOR A q 14 PHONE <br />SUBCONTRA T R ADDRESSCI Y STATE/ZIP / <br />LICENSE 57 11 C-61 ❑ D-09 1 Other NUMBERZAM/ EXPIRATION DATE <br />DOMESTIC 4ELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE omestic/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 ❑ Soil Boring(S) # of borings D Geotechnical # of borings <br />❑ Out-Of-Servic ell ❑ Out -Of -Service Well Renewal El Cross -Connection Repair <br />❑ New Pump )APump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter I I 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 11 Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft CI Neat Cement (94 lb bag/5-10 gal wate/) ❑ Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) I 1 Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other I I Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller I I Pump Contractor 11 Other <br />❑ Concrete Pedestal LDimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible ❑ Turbine ❑ 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 />SIGNED <br />- PLEASE CALL (20 <br />DATE <br />4y�;�LDEPARTMENT USEIONLY <br />Application Accepted By Date r rL <br />Grout Inspection By Date <br />Pump Inspection By 1 Date 7i <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area Jt I j I Employee ID# 41 %Vyt <br />Fi SPECIAL Well Permit <br />LI WAIVER Received <br />Constructed Well Depth ft <br />T <br />m <br />D <br />0 <br />v <br />M <br />M <br />m <br />u, <br />PE <br />Codes <br />Sc Received (--CheckV <br />Info B <br />Amount Date Permit/ Invoice # Well ID# <br />Remitt Service Request # <br />� � <br />J <br />31-A2, P 380 <br />EHD 43-06 8/01/16 <br />WELL /PUMP PERMIT <br />