WP0038581 - 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` t CIryrZjP c/ 12 � � �� -70L T-P D CROSS STREET C APN ��/ /�� ARC[EL S LAND US PPLIG In # A OWNER NAME /`E// /Ll/tif/St Z- r rlAZ lr IPQ 1 JPHON _ 200 �! OWNER ADDRESS CrTYISTATEMP CONTRACTOR L) / P.ONN ^, CONTRACTOR ADDRESS V CrTY(STATEMP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑C-57 1 ;i D-09 G Other NUMBER EXPIRATION DATE DOMESTIC WELLS PuNG:❑General MineraVColiform Bacteria(4391)❑Dibromochlompropane(4392)L Arsenic(4393) INTENDED USE Domestio/Private I Irrigation/Agricultural ❑Industrial a Water Quality Monitoring ❑Soil Sampling/Characterization F'Public Water System If different ftotn Owner: Water System Name Contact Name or Phone Number TYPE OF WORK 7 New Well ❑Replacement Well U Well Alteration/Modification C Other 2 Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings 7 Geotechnical If of borings Out-OfService Well ❑Curt-Of-Service Well Renewal ❑Cross-Connection Repair New Pump Cl Pump Replacement ❑Pump Repair 7 Raise Well Casing WELL CONSTRUCTION Drilling Method I Mud Rotary i Air Rotary n Auger I Cable Tool I Push Point fi Other Proposed Well Depth ft Excavation in diameter n Open Bottom ❑Gravel Pack/Gravel Size in diamet v ❑Conductor Casing in diameter / Conductor Casing Depth It Well Casing Diameter_in Thickness/Gauge/ASTM Schad ❑Steel ❑Plastic 11 Stainless Steel ❑Other Grout Seal Depth ft n Neat Cement(94 lb bag/5-10 gal water) n Sand Cement Sack mi:d7 . ® �O�D i I Bentonite(20%solids) I Other y C (� Grout Placement Method 11 Pumped Free Fall U Other J Retardant/Accelerator(name) SRT u PEDESTAL Installed By i Driller I Pump Contractor r Other ,J' Concrete Pedestal_Dimensions:Width It Length it Thick in U Christy Box I_Stove Pipe PUMP 1 J Submersible?Turbine ❑Other HP Pump Set ft Standing Water Level ft 1 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. MI CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)95 -7697 SIGNED TITLE 42G/ i' '✓' DATE IF Mae RECE JUL 16 LW 11-17 ENVIRONMEN PERMIT/SE zt- DlXe A,R - ENT U E 7 L Application Accepted By Area Employee ID#� Grout Inspection By Dale ❑ SPECIAL Well Permit Pump Inspection By e, Date ^ ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Sc Received Amount Date Permitl Invoice S Well ID# COOS Info emitted Service Request# EHD 4306—i d 4/14/18 WELL/PUMP PERMR