Laserfiche WebLink
-T t- ` <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br />CALL <br />ZU9 953-7b97 FOR INSPECTIONS I <br />tAI-IKtS 1 YEAR FROM UATE ISSUED <br />110 <br />-7 <br />/ <br />JOB ADDRESS <br />CITY/ZIP <br />PARCEL SIZE <br />LAND USE APPLICATIONPAY # <br />CROSS STREET <br />A N <br />NAME <br />fcOWNER <br />PHONE <br />y^,� <br />� I <br />t <br />OWNER ADDRESS J <br />CITY/STATE/ZIP <br />-LZ <br />CONTRACTOR <br />PHONE V <br />fTATE/ZIP <br />CONTRACTOR ADDRESS ' <br />in 10 &--:kI <br />CITY/S <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTPR ADDRESS <br />rV <br />CITY/STATE/ZIP <br />I <br />LICENSE C-57 ❑ C-61 <br />❑ D-09 ❑ Other <br />NUMBER <br />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 Uontact Name or Phone Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />ElMonitoring Well(s) # of wells ElSoil Boring # of borings s) ❑ Geotechnical # of borings <br />❑Out-Of-Service,WW II ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />F1 New Pump M PumD Replacement F1 Pump Repair F] Raise Well Casinq <br />Drilling Method E] Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other <br />Proposed Well Depth 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 Sched ❑Steel [-]Plastic❑Stainless Steel F] Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />E] Concrete Pedestal dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />if <br />PUMP [I Submersible❑Turbine ❑Other HP Pump Seth 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 />SIGNED <br />EPARTMENT USE ONLY <br />Application Accepted By�a Date J(-7,// <br />Grout Inspection By Date <br />Pump Inspection By W-A'S&—'�-j4Vfn$" Date -) [to I ►7 <br />Soil Boring Inspection By Date <br />COMMENTS <br />T <br />Area Employee ID#iC±`� <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE SC Receivedhec <br />Codes Info B ash <br />Amount <br />Remitted <br />Date Permit/Invoice # Well ID# <br />Service Request # <br />110 <br />-7 <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />