WP0038813 - 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 ` EXPIR S 1 YEAR FROM DATE ISSUED JOB ADDRESS t cJCIl,CITY/ IP m 7 J� �J q D CROSS STREET N r PARCEL SIZE D USE APPLICATION# A rn OWNER NAME �C LLC 4 PHONE (n OWNER ADDRESS A v CITY/STATE/ZIP- CONTRACTOR PHONE/LL q__�4UQQl�l'� CONTRACTOR ADDRESS CITY/STATE/ZIP L 4V7— SUBCONTRACTOR PHONE SU13CONTRACTO ADDRESS C Y/STATE/ZIP / LICENSE C-57 ❑ C-61 El D-09 11 Other NUMBER EXPIRATION DATE < DOMESTI WELL SAMPLING: I General Mineral/Coliform Bacteria(4391) 1 1 Dibromochloropropane(4392) I Arsenic(4393) INTENDED USE ❑ Domestic/Private El Irrigation/Agricultural 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 ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pum )4ump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool r l Push Point ❑ Other Proposed Well Depth ft Excavation in diameter I-1 Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other I I Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal []Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft I HEREBY CER IFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, 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 WORK S MPENSATION LAWS. N 4 HO DV NCE E REQUIRED FO INSPE TIONS -PLEASE CALL (209))9 -769 SIGNED MITITLE DATE l 7 AIRE NT Ey UN O IN H1 DiDE?AETIVF:Nr DEPA.RTMENT USE ON Y Application Accepted By Date �� Area Employee ID# Grout Inspection By Date ❑ S CIA Well Permit Pump Inspection By ° Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount ate Permit/ Invoice# Well ID# Codes Info B Cas Remitted Service Re uest# s'U j! EHD 43-06 8/01116 WELL/PUMP PERMIT