Laserfiche WebLink
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 />JOB ADDRESS LPCi CITY/ZIP j/ 0V//CiY(,/,[L44 L -f7 /`/Cf ✓ <br />CROSS STREET APN �f J� O 1 PARCEL SIZE O 7 _) LAND USE APPLICATION # <br />OWNER NAME Dw <br />r PHONE <br />OWNER ADDRESS CITYISTATE/ZIP <br />CONTRACTOR awpPHONE <br />CONTRACTOR ADDRESS CITY/STATE/ZIP <br />SUBCONTRACTOR Al PHONE <br />SUBCONTRA7157 <br />ADDRESS C STATE/ZIP <br />LICENSE ❑C-61 [I D-09 [I Other NUMBERqhM�L EXPIRATION DATE <br />DOMESTIC ELL 30 <br />PILING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br />Public Water System <br />If different from Owner: Water bystem Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />El Monitoring Wells) # of wells El Soil Boring # of borings s) E] Geotechnical # of borings <br />❑ Out -Of -Service VV911 ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />I-1 New PUmD umD ReDlacement I-1 Puma Repair n Raise Well Casino <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 mix/7 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 />[1Concrete Pedestal dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP U] Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CEI(TiFY 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,CbMPENSATION LAWS. <br />SIGNED <br />EPARTMENT U E ONLY <br />Application Accepted By Date <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />T <br />m <br />D <br />v <br />v <br />m <br />m <br />CnP <br />AreatlI Employee ID#_ na_ <br />❑ SPECIAL Well Permit l <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE Sc Received <br />Codes Info B <br />Check#/ Amount Da <br />Cash Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />