WP0038231 - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMIT P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS E PIRES 1 YEAR FROM DATE ISSUED amJOB ADDRESS CITY/ZIP < ` m ff�� JC/ D CROSS STREET-HAAWO V D 1 - PARCEL SIZE 2i___nND USE APPLICATION# S - OWNER NAME i PHON P AA )Q S-� OWNER ADDRESS �J�CITY/STATE/ZI Eta ` CONTRACTOR p PHONE/ T✓Q�L�j CONTRACTOR ADDRESS /� CITY/STATE/ZIP Q&rj 1"A 425,1_111s: SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS C Y/STATE/ZIP LICENSE C-57 [_I C-61 ❑ D-09 I 1 Other NUMBER qIAMOEXPIRATION DATE J� DOMESTIC WELL SAMPLING: ;General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE ❑ Domestic/Private VIrrigation/Agricultural LI Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells LI Soil Boring(s) #of borings ❑ Geotechnical # ygb Out-Of-Service Well El Out-Of-Service Well Renewal LI Cross-Connection Repair 9 2018 ((❑ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing SA#JOq WELL CONSTRUCTION HH ONMENT,q� Drilling Method `Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Nwr Proposed Well Depth GL% ft Excavation in diameter n Open Bottom )<Gravel Pack/Gravel Sizea, 4ii(diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter 10 in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth._. .5-0 ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water [Bentonite(20%solids) I I Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ,%Pump Contractor LI Other ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick===C==in ❑ Christy Box ❑ Stove Pipe PUMP Wp Submersible❑ Turbine LI Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORD ANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENON LAWS. MINI �t RLADVANCE NOTICE REQUIRED FOR INSPECTI - NS -PLEASE CALL (209) 953-77i697v SIGNED ' T TLE DATE PC 1V i DETMENT USE/ONLY Application Accepted By Date Area Employee ID# Grout Inspection By Date (l ❑ PECIAL W@II Permit Pump Inspection By Date 1 2rj LI WAIVER Received (� Soil Boring In tion By Date Constructed Well Depth G t2`� ft COMMENTS PE Sc Received Check Amount Date Permit/ Invoice# Well ID# Codes Info B ash Remitted Service Request# a3 7�L Pon EHD 43-06 6/01/16 WELL/PUMP PERMIT