Laserfiche WebLink
P'z <br />WELUPUMP PERMIT <br />• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209) 4683420 <br />NON-REFUNDABLE PERMIT 11C``A__LL 209 953-7697 FOR INSPECTIONS EXPI ES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS \ Q . 11i CRY/ZOL KPI <br />IP �/ Vl <br />;51- <br />CROSS STREET Qr `(1 \ O La APN �7­y/J OSO­ �Z PARCELSIZE F^kAN�`DU,^S'4�APPLICATION # <br />OWNER NAME a Rl� (� �10(�1,�1y5�/ PAW- I III <br />% V n� /I�PHONEy )L slid -/' <br />OWNER ADDRESS tato V\Q L-4/ �lG"L 1..��� CRY/STATE/ZIPCAA jtV",_LA �'1.'UV'10 <br />CONTRACTOR PHONE <br />CONTRACTOR ADDRESS CITYISTATE/ZIP <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br />LICENSE L C-57 C-61 C D-09 C Other NUMBER EXPIRATION DATE <br />DOMESTIC WELL SAMPLING: i' General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE C Domestic/Private L Irrigation/Agricultural L Industrial ❑ Water Quality Monitoring D 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 L Replacement Well C Well Alteration/Modification Other <br />Mo itoring Well(s) # of wells L Soil Boring(s) # of borings Geotechnical # of borings <br />ut-Of-Service Well L Out -Of -Service Well Renewal L Cross -Connection Repair <br />NewPump L Pump Replacement L Pump Repair Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary Air Rotary L Auger E Cable Tool - Push Point - Other <br />Proposed Well Depth ft Excavation in diameter L 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 L Steel C Plastic Stainless Steel L Other <br />Grout Seal Depth ft D Neat Cement (94 lb bag/5-10 gal water) L Sand Cement sack mix/7 gal water <br />- Bentonite (20% solids) ❑ Other <br />Grout Placement Method D Pumped L Free Fall E Other L Retardant / Accelerator (name) <br />PEDESTAL Installed By C Driller D Pump Contractor L Other <br />L Concrete Pedestal LDimensions: Width It Length ft Thick in L Christy Box E Stove Pipe <br />PUMP C Submersible- Turbine D Other HP Pump Set It 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 1 AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CAF' I1,(209) 953-7697 <br />SIGNE TITLE <br />!96A(-4—. <br />LV' DATE <br />rn <br />0 <br />m <br />N <br />C �IVED <br />:c z o imp <br />EHD43-06 6/01116 WELL [PUMP PERMIT <br />HEALTH <br />DEPARTMENTTUSY <br />Application Accepted By <br />Date � <br />Are Employee ID# <br />Grout Inspection By <br />of Date <br />SPECIAL Well Permit <br />Pump Inspection By <br />Date /46vz <br />WAIVER Received <br />Soil Boring Inspection By <br />Date <br />ConLj"d Well Depth <br />ft <br />COMMENTS 1! f -O iiLA <br />EHD43-06 6/01116 WELL [PUMP PERMIT <br />HEALTH <br />