Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOkQUIRI COUNTY ENVIRONMENTAL HEALTH DEPARTMENL' , 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 F05 INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS L C bre <br /> CITY/ZIP _ m <br /> CROSS STREET-� ! APhN ��j�•��U ' `IT PARCEL SIZE [ � LAND USE AP LICATION# <br /> OWNER NAME I � PHONEi /J (�� Cn <br /> OWNER ADDRESS n �i� +� U /� O CITY/STATE/ZIP r /�Z t /( <br /> CONTRACTOR �//✓7/\ j;}}t�Pas "el 1,4 /�/' � LI tJ� <br /> CONTRACTOR ADDRESS too w j �-� e CITY/STATE/ZIPj rl LN <br /> SUBCONTRACTOR �l/�f� L_ PHONE-PHONE-3 -2,,, <br /> c.-2 Or'- <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE 4!9t_-57 El C-61 F-1D-09 ❑Other NUMBER 3 EXPIRATION DATE < <br /> DOMESTIC WELL SAMPLING:[-]General Mineral/Coliform Bacteria (4391)❑Dibrom hloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private<rrigation/Agricultural ❑Industrial ❑Wate Q ali Monitoring E]Soil Sampli zation <br /> F1 Public Water System <br /> If different from Owner: Water System Name Contac ame or one um r <br /> TYPE OF WORK ' New Well ❑Replacement Well ❑Well Alteration/M dificati, El Other <br /> of borings o or' <br /> El Monitoring Well(s) #of wells ❑Soil Boring(s) ❑Geotechnl <br /> F]Out-Of-Service Well ❑Out-Of-Servi a ewal ❑Cross-Connection Repair pER 'TENTALH� <br /> �lew Pum El Pump Replacement ED]Pump Rep <br /> e it ❑Raipe Well CasingSER STH <br /> WELL CONSTRUCTION <br /> Drilling Method<Mud Rotary ❑Air Rotary ❑Auger ❑Ca e Tool ush Point Other <br /> Proposed Well Depth �s ft Excavation in diame El tom Gravel Pack/Gravel Size in diameter <br /> F]Conductor Casing in diam er / ducto �a�ing Depth ft <br /> Well Casing Diameter,Q in Thickness/Gaug AS ch d ❑Steel lastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth !G ft ❑Neat Ce nt 9 bag/ 1 al water) [ land Cement f(}�j sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method ❑Pumped ❑Free F ther ❑R tarda t/Accelerator(name) <br /> PEDESTAL Installed By �<Driller Pump n ractor, ther <br /> ❑Concrete Pedestal EDim Sion : i th e,1 ength ft tick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible❑Turbne Ot HP Pump Set ft Standing Water Level ft <br /> �( <br /> I HEREBY CERTIFY THAT I HAVE PREPAR T APPLICAT7 ON AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE AWS, 'D U AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONT RS STAT LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. / <br /> MINI M 4 H UR ADVA14CE NOTICE UIRED R INSPECTIONS - PLEASE CALL (209)) 953-7697 <br /> SIGNED l` eJ, ; DATE <br /> v <br /> � <br /> Ilt-1 I <br /> DEPA TMENT U E NLY <br /> Applicaiiun Accepied By55* Date Z Area 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 JTAK,�5� <br /> PE Sc Received Check#/ Amount Permit/Codes nfo B Cash emitted Date Service Request# Invoice# Well ID# <br /> -7 ZS <br /> IN <br /> EHD 43-06 8/01/16 j,f ,�j WELL/PUMP PERMIT <br />