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 P RMIT C LL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />/ ) (— rte: <br />JOB ADDRESS CITY/ZIP <br />CROSS STREET /00APN PARCEL SIZE " ti ! LAND USE APPLICATION # <br />OWNER NAME 1 C PHONE <br />OWNER ADDRESS OC CITY/STATE/ZIP <br />CONTRACTOR ( PHONE��1 <br />CONTRACTOR ADDRESS24CITY/STATE/ZIP <br />SUBCONTRACTOR f4wl 4q PHONE <br />SUBCONTRACTOR ADDRESS ITY/STATE/ZIP <br />LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br />DOMESTIC 4ELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USEDomestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring E]Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Uontact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />El Monitoring Well(s) # of wells E] Soil Boring # of borings s) ❑Geotechnical # of borings <br />F-1 Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />❑ New Pump ApumpReplacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method E] Mud Rotary ❑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 E] Other <br />Grout Seal Depth ft ❑ Neat Cement (94 /b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Benton ite (20% solids) ❑Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By [-]Driller ❑Pump Contractor ❑ Other <br />E] Concrete Pedestal dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP ®Submersible❑Turbine ❑Other HP I 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 />r <br />NIj�M%U�M�,,%4�H) R DVA/�N%/C�/E� NOTICE REQUIRED FOR=PECT/S -- PLEASE CALL (209) 769SIGNEDI A�X/XYY.1 /I' i ' " TITLEf'I ' DATE IML) -11-1 <br />I/W PARTMENT/USE ONLY <br />4 <br />Application Accepted By �^ Date / <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area C G Employee ID# /'h/Ij( U <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />T <br />m <br />D <br />v <br />v <br />m <br />m <br />N <br />ur <br />PE <br />Codes <br />SC Receivedhec <br />Info B <br />Date Amount <br />ash Remitted <br />Permit/ Invoice # Well ID# <br />Service ftq% St # <br />J <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />