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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I- CITY21P ` G 0 <br /> V1 `�1� D <br /> CROSS STREET �i^( AP N PARCEL SIZE v'V r NO USE APPLICATION# v <br /> OWNER NAME �{,/Gd�1lS V p <br /> m <br /> PHONE in <br /> tr ��o Ga Zc12 <br /> OWNER ADDRESS W/7L � CITYISTATE/ZJP / <br /> CONTRACTOR K lief/i nn fe d-p r- /-� r��p,�t�� PHONE 1 -1 / <br /> CONTRACTOR ADDRESS '�+/0 I, i / S�`�'r'r"CITY/STATE/ZIP S'�Gk-TDK, <br /> SUBCONTRACTOR W Y�` I tr PHONE <br /> t 1 _ `` <br /> SUBCONTRACTOR ADDRESS11A 14.G CITY/STATE/ZIP r II ✓( <br /> t <br /> LICENSE IN C-57 ❑C-61 ❑D-09 ❑Other I NUMBER EXPIRATION DATE 17-0 <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)i_Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring 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 ❑Soil Borings) #of borings .A Geotechnical 2S 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 ISL Mud Rotary ❑Air Rotary 7 Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth l�A—oo ft Excavation in diameter ❑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 Schad ❑Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft 4 Neat Cement(94 lb baglSfO gal water) ❑Sand Cement sack mix/7 gal water <br /> Ll Bentonite(20%solids) ❑Other <br /> Grout Placement Method VFumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box _-Stove Pipe <br /> PUMP ❑Submersible❑Turbine ❑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. 1 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 48 F R ANCE NOTICE REQUIRED FOR I SETIQNS-PLEASE CALL(209)953-76q7 <br /> SIGNED r TITLE ``� .Y/' DATE <br /> 14 <br /> NT <br /> 8 <br /> �P&&/TMENT U ZZE O L <br /> Application Accepted By ate " AreaVn <br /> Employee ID# <br /> Grout Inspection By Date SPECIAL ell Permit <br /> Pump Inspection By Date WAIVER OCBIVed <br /> Soil Boring Inspec'on By Date ft <br /> Constructed Well Depth <br /> COMMENTS D.5 / Q� �.� 32-/n& <br /> 1 10 Y <br /> PE Sc Received Check#/ Amount PermiV <br /> Codes Info Cash emitted Dat Service Re uest# Invoice# Well ID# <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />