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 /> Ln <br /> Q ' ` firoxcy 4 �© <br /> JOB ADDRESS 1-13 9 f 1 d P � L Q C e, CITY/ZIP �_� rnM1 <br /> Ko-C, gA.APN iso -3 ip_ y <br /> CROSS STREET . PARCEL SIZE -55 LAND USE APPLICATION# x <br /> OWNER NAME Mesal Rosas PHONE 2_1 CH - 0, <br /> OWNER ADDRESS 2_3&t-}�runic )-�-e-�. CITY/STATE/ZIP-�-y-0_c y , C_F- 0153_1 3 <br /> CONTRACTOR C aS ` i PHONE Sy J ]�� S <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP�_ b a� C R `i 5-3S0 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP �^ <br /> LICENSE C-57 I I C-61 f_l D-09 I I Other NUMBER q EXPIRATION DATE 7 <br /> 2=0— <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) i 1 Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private IJ Irrigation/Agricultural I i Industrial ❑ Water Quality Monitoring i I Soil Sampling/Characterization <br /> 2 Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK>(New Well Xeplacement Well I I Well Alteration/Modification ❑ Other <br /> I I Monitoring ell(s) #of wells I I Soil Boring(s) #of borings I I Geotechnical #of borings <br /> ❑ Out-Of-Service Well Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> IJ New Pump 11 Pump Replacement Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary �ii AirKir`` of Auger iJ Cable Tool ❑ Push Point Other <br /> Proposed Well Depth �Tt'"� Ocavation in diameter Open Bottom Gravel Pack/Gravel Size_ in diameter <br /> I I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter In Thicknauge/ASTM Schede'@!,,� I I Steel Plastic I Stainless Steel I I Other <br /> Grout Seal Depth_ 1�0 t eat Cement(94/b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) I I Other <br /> Grout Placement Method Pumped i' Free Fall ❑ Other III Retardant/Accelerator(name) <br /> PEDESTAL Installed By I l Driller ump Contractor I Other <br /> LI Concrete Pedestal I IDi ensions:Width ft Length ft Thick in i Christy Box i i Stove Pipe <br /> PUMP ❑ Submersible,1 Turbine i i 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 48 HOUR ADVANCE NOTICE REQUIRE NSPECTIONS - PLEASE CALL (209) 953-7697 <br /> • - to <br /> SIGNED ITLE �, DATE <br /> Allb <br /> I <br /> h f 4, Doo <br /> A <br /> DTMENT USE ONLY <br /> E AR <br /> i 1�" <br /> Application Accepted By in// <br /> Date �`O Area l Employee ID# <br /> Grout Inspection By �/1r�eSllCy ' f Date 11 u I SPECIAL Well Permit <br /> Pump Inspection By Date I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS AZ ` <br /> PE SC Received eck#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> V `� <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />