WP0038905 - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMIT 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 EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CITY/ZIP 51 A 10(1 Ott, 19;V m �j�j(� D CROSS STREET Y\� V APNQ�'01- ✓r 3 - 0A PARCEL SIZE _LAND USE APPLICATION# A OWNER NAME I �� I PHONE OWNER ADDRESS 1 I�I I`� ` , `/I v CITY/STATE/ZIP t )��1 • 1 V� ��✓ CONTRACTOR 1�J�/II IS ✓1 I N PHONE CONTRACTOR ADDRESS J�Lj CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP f 1 ✓�y(� LICENSE "KC-57 11 C-61 ❑ D-09 I I Other NUMBER V�"U 12 EXPIRATION DATE �/ 'I-1 DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) 1 Dibromochloropropane(4392) Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial I1 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 11 Monitoring Well(s) #of wells [I Soil Boring(s) #of borings IJ Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump ❑ Pump Replacement ❑ Pump Repair I1 Raise Well Casing WELL CONSTRUCTION Drilling Method Mud Rotary 11 Air Rotary ❑ Auger �❑ Cable Tool 1_I Push Point ❑ Other Proposed Well Depth � ! Ift Excavation �1 in diameter I I Open Bottom Gravel Pack/Gravel Size_in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter V in Thickness/Gauge/ASTM Sched U0 1.1 Steel Y Plastic L1 Stainless Steel ❑ Other Grout Seal Depth IOU ft ❑ Neat Cement(94 lb bag/5-10 gat water) ❑ Sand Cement sack mix/7 gal water Bentonite(20%solids) 11 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 I I 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 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 WORKERS COMPENSATION LAWS. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPE1CT ONS - PLEASE CALL (209)) 953--7]697 SIGNED TITLE_ II DATE N vio m 0 A IN VI Fli 11 H DE PART F 1;4 EPARTMENT //U, SE ON LY /' A Application Accepted By 2�/q/'�/��- / Date IU �d Area /`'� Employee ID# �G Grout Inspection ByV Date 13 L' a1 ty((� F1SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received eck#/ Amount ate Permit/ Invoice# Well ID# Codes Info Remitted Service Request# y �� ST- 2 v lot ► 0 3,l 3(p 12 1 "s, 10 l1 EHD 43-06 8/01/16 WELL/PUMP PERMIT