Laserfiche WebLink
1'U <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 IAJ <br />CALL 209 <br />953-7697 FOR INSPECTIONS tAVIKtJ I TEAR FROM UA It I55UtU <br />JOB ADDRESS <br />t •J J✓ <br />/ IP c <br />CITY/ZIP ! 1 CI <br />CROSS STREET <br />! / / Or <br />APN Q) <br />1 <br />J <br />5 ( 1 � PARCEL SIZE U•_LAND USE APPLICATION # <br />OWNER NAME <br />circ° <br />Pl �( ` ! <br />PHONE <br />2. 3 3 B l Al <br />liey/-/, es <br />go( CITY/STATE/ZIPJ f C^ J 7 <br />OWNER ADDRESS <br />I <br />CONTRACTOR <br />wV�'t'C J <br />PHONE <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE ❑ C-57 ❑ C-61 ❑ D-09 L -I Other <br />CITY/STATE/ZIP <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: - General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USEomestic/Private 11Irrigation/Agricultural n Industrial 11 Water Quality Monitoring Li 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 1-1 Soil Boring(s) # of borings ❑ Geotechnical <br />❑ Out -Of -Service Well ❑" Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br /># of borings <br />❑ New Pum ump Replacement ❑ Pump Repair ❑ Kalse vveii cash <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary 1.1 Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter 11 Open Bottom 1_I Gravel Pack/Gravel Size in diameter <br />LI Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched [I Steel ❑ Plastic LI 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 />I Ll Concrete Pedestal []Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP Submersible ❑ Turbine f 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 />MINIMUM 24 HOUR ADV/AWE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 5n769 / <br />SIGNED �j/LSC%% �/ 4TITLE O �t/N/ DATE / �Tj <br />m <br />D <br />0 <br />0 <br />A <br />m <br />En <br />DEPARTMENT USE ONLY <br />Application Accepted B421Date L Area Employee ID#� w` <br />Grout Inspection By Date ❑ SPECIAL Well Permit <br />Pump Inspection By J Date 2 Ll WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS - p11 q4, 'I- w 01-1 <br />PE <br />Codes <br />SC Received Check#/ Amount Permit/ <br />Info B Cash Remitted Date Service Re uest # Invoice # Well ID# <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />