Laserfiche WebLink
1 r <br /> WELL/PUMP PERMIT r <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-34 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> (1 f . Ln <br /> JOB ADDRESS O ` At `�S �(}• CITY/ZIP L.Q�t1 9SZ4-n m <br /> 1 0 <br /> CROSS STREET 1`L c e ` L_) V'- V Q APN OLI—I�p(�3 I PARCEL SIZE LAAN�D,US ION# <br /> r" u T ai <br /> OWNER NAME 1 /�•�-� \ �CQ' �. \( �P,HO1NE =��C1 C�V `✓? <br /> OWNER ADDRESS I��y 1 \ V Y1C. I�i�'• CITY/STATE/ZIP `SCJ U 1 CA <br /> CONTRACTOR UL CZA\ O PHONE 't599 S' I L b5 <br /> CONTRACTOR ADDRESS l l _ CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/S�TATEIZ�IP2 <br /> LICENSE *__57 El C-61 [ID-09 ❑ Other NUMBER X/S!o V �7 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) 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 Xeplacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) a of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal LI Cross-Connection Repair <br /> ❑ New Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTIO <br /> Drilling Method Mud Rotary ❑ Air Rotary 11Auger F1Cable Tool 11Push Point Cl Other <br /> Proposed Well Depth j f.O ft Excavation Li_ in diameter I 1 Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑ Conduct oe acing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter U in Thickness/Gauge/ASTM Sched [I Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth�_ft 1-1 Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Bentonite 200%solids) ❑ Other <br /> Grout Placement Method Pumped ❑ Free Fall ❑ Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal F1 Di ensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible[-] Turbine fl 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICEREQ D FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE DATE <br /> Ile <br /> N <br /> O QL 1N <br /> E T <br /> ___0 EN RIMENE u ULY <br /> Application Accepted By I Date nta Area `7 Employee ID#� <br /> Grout Inspection By '_� Date �`� ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS � �� <br /> PE SC Received heck#/ Amount Date Permit/ invoice# Well ID# <br /> Codes Info B Remitted Service Request# <br /> I - 5 Z <br /> E'4D 43-06 8101/16 WELL/PUMP PERMIT <br />