WP0038383 - Laserfiche WebLink

Home Browse Search

WELUPUMP PERMIT SAN JoAOUIN 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` Wtt6fCITYMP r�} ��J CO r'Ai `\��//I D CROSS STREET LLs�-'-T AP�1N \ /1 ARCEL SUS PLI TON# o LAND OWNER NAME (/ iVS L.- TL I/�_+�rC�DI / I sho PH. ^ In OWNER ADDRESS7S7 ✓� CnY/STATE P CONTRACTOR �f1 U PHDNE^^A% ` L7t� CONTRACTOR ADDRESS dw)` cRYISTATEmP�-N,e SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CRYISTATE0P LICENSE n C-57 1 ❑D-09 ❑Other NUMBER EXPIRATION DATE DOMESTIC WELL S PLING:a General MineraUColiform Bacteria(4391)❑Dibromochloropropane(4392)E Arsenic(4393) INTENDED USE Domestic/Private :1 Irrigation/Agricultural ❑Industrial C Water Quality Monitoring ❑Soil Sampling/Characterization R Public Water System If different from Ovmer: Water System Name Carted Name or Plwne Number TYPE OF WORK 7-New Well ❑Replacement Well ❑Well Alteration/Modification C Other C Monitoring Well(s) #of wells D Soil Boring(s) 4 d bminp 7 Geotachnical If of borings Out-OfService Well D Out-Of-Service Well Renewal ❑Cross-Connection Repair New Pum ❑Pump Replacement ❑Pump Repair 7 Raise Well Casing WELL CONSTRUCTION Drilling Method -1 Mud Rotary i Air Rotary n Auger F Cable Tool l Push Point n Other Proposed Well Depth ft Excavation in diameter n Open Bottom a Gravel Pack/Gravel Size in diameter 0 Conductor Casing in diameter / Conductor Casing Depth It j Well Casing Diameter_in Thiclmess/Gauge/ASTM Schad n Steel ❑Plastic n Stainless Steel ❑Other 1 20 Grout Seal Depth ft n Neat Cement(94 lb bagt&10 gal water) n Sand Cement sack mnd7 vfk A �O�D i1 Bentonite(20%solids) -1 Other H V O,� (� Grout Placement Method ❑Pumped G Free Fall u Other J Retardant/Accelerator(name) PEDESTAL Installed By .i Driller I- Pump Contractor I- Other Concrete Pedestal_Dimensions:Width ft Length it This* in u Christy Box Stove Pipe MF/1/� PUMP 1 Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT 1 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 COMPENS TION LAWS. MI B fJCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)95 -7697 SIGNED TITLE e2CU�✓y— DATE RECE10 I T-� JUL 16 ENVIRONMEN I PERMIT/SER. D=&R�,MNT U E O/ L Application Accepted By L Area Employee ID� Grout Inspection By Date� ❑ SPECIAL Well Permit Pump Inspection By Date C WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Amount Date PermW Invoice# Well ID# coos Info fitted Service R nest# EHD 43-06 revised 4/14/18 WELL/PUMP PERMrr