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 95.3-7697 FOINSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /ZIP rW�CJ 7S 1 I / <br /> (AGI�LAL <br /> D <br /> CROSS STREETC�I°t (�APN �^' 1 Y P RCEL SIZE I� LAND USE APPLICATION# v <br /> A <br /> 27 <br /> OWNER NAME / � r_ N� _j r Cil C�� PHONE oy,+ <br /> OWNER ADDRESS C ( � { CITY/STATE/ZIP <br /> 1 13 <br /> CONTRACTOR _ \'�G��1}' I� /�/�,/� C PHONE �,I j�jt Q �Ifs <br /> CONTRACTOR ADDRESS 7 WyI rc i j r"I � J�e 10CITYISTATE2IP Skk�'! C��`/ /Y 20A <br /> SUBCONTRACTOR Y Z PHONE` G '1700 <br /> SUBCONTRACTOR ADDRESS UT r ITTATE2I <br /> CY/SP l5 c- <br /> y � G— <br /> LICENSE C-57 D C-61 ❑D-09 ❑Other NUMBER�� EXPIRATION DATE D <br /> DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ❑Inigation/Agricultural ❑Industrial ❑Water Quality Monitoring YjSoil 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 ❑Soil Boring(s) #of bodngs Geotechnical a of borings <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 4 Mud Rotary ❑Air Rotary IjAuger D Cable Tool D Push Point D Other <br /> Proposed Well Depth_S73 12 ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft Sj Neat Cement(94/b bag/5-10 gal water) ❑Sand Cement sack mW7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method Pumped ❑Free Fall D Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller D Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width it Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible Turbine ❑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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMYM 4 ADVANCE NOTICE REQUIRED FOR I SP C/T(IIONS-PLEASE CALL(209)953--7697f�/� J. <br /> SIGNED TITLE �{] [( DATE J0( ! <br /> Ira <br /> 19 VA41A <br /> All I <br /> F <br /> PA MENT US ON �/,y <br /> Application Accepted By f Date Area Employee ID*J4; ,'/C4 <br /> Grout Inspection By Date ❑ PECIAL ell Permit <br /> Pump Inspection By Date ❑ WAIVE ReCBIVed <br /> Soil Boring Inspection By / `r Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Dat Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Re uest# <br /> M <br /> EHD 43-08 revised 4/14/18 WELL/PUMP PERMIT <br />