Laserfiche WebLink
• I � <br /> • WELL/PUMP PERMIT <br /> SAN J0,AQUIM COUNTY ENVIRONMENTAL HEALTH DEPARTMENV 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> 'NON-REFUNDABLE PERMIT CALL <br /> � 209)953-7697 FOR INSPECTIONS /EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ln <br /> Z � <br /> JOB ADDRESS ' 4 +QJ�j CITY/ZIP D <br /> '// <br /> CROSS STREEV'' L4 �+- APN O2,,�45;0 ' `� PARCEL SIZE � � LAND USE AP LIGATION# <br /> OWNER NAME A/ I (� �[ ��t! ' 1-7� PHONE ' <br /> OWNER ADDRESS 5 �J V o r t 2- 0 CITY/STATE/ZIP & N! q l5 v k <br /> CONTRACTOR 'PHONE <br /> CONTRACTOR ADDRESS / J �'�r J� d -/ �J CITY/STATE/ZIP <br /> r <br /> SUBCONTRACTOR ,c"2 7 i Pnn PHONES <br /> r <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ' <br /> LICENSE 01t,-577 [IC-61 F1D-09E]Other NUMBER3 S EXPIRATION DATE 0<1- <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromg6hloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private rrigation/Agricultural ❑Industrial ❑WateyQ aIi y Monitoring El Soil Sampli zation <br /> ❑Public Water System <br /> If different from Owner Water System Name j -o-nTa-cl <br /> ame or one um r <br /> i <br /> TYPE OF WORK '[ New Well ❑Replacement Well ❑Well Alteration/Mp11 ificati Other <br /> �ofborings E]❑Monitoring Wells) #of wells El Soil Boring(s) ! ❑Geotechnr'k% toor <br /> ❑Out-Of-Service Well ❑Out-Of-Service ewal ❑Cross-Connection Repairp N7AL <br /> Nlew Pum Ll Pump Replacement [_]Pump Re air [:1Raise Well CasingERM1Tj$E/� N�'L7N <br /> WELL CONSTRUCTION /� <br /> Drilling Method%�Mud Rotary [-]Air Rotary ❑Auger ❑Ca�e Tool ��Push Point �Other <br /> Proposed Well Depth 6; c'3? ft ExcavationPd <br /> in diamet'�0+/ll E]Open 4om J<Gravel Pack/Gravel Size "� in diameter <br /> F1 Conductor Casing in diamduct o Ewing Depth ft <br /> Well Casing Diameted�'' in Thickness/Gaug ❑StN�:nd <br /> stic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ., ft ❑Neat Ceag/ 10 al water) Cement 1,�; sack mix/7 gal water <br /> [-]Bentonite(20%solids) ❑Other <br /> Grout Placement Method ❑Pumped ❑Free F the' ❑R tardant/Accelerator(name) <br /> PEDESTAL Installed By o<Driller Pump on'actor, the' <br /> []Concrete Pedestal dim sion i th eZ_ ength ft tick in ❑Christy Box ❑Stove Pipe <br /> PUMP ,.ZSubmersible❑Turbne Ot HP '� Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPAR T APPLI TON 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINI M 4 H UR ADVANCE NOTICE UIRED R INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> J, <br /> 7­12 <br /> SIGNED ;«�/y/ DATE [ 2.— <br /> L' <br /> Cd <br /> DEPA TMENT USE ONLY <br /> App;icaiiun Accepieu By Date_(z Area Employee ID#�Q� <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Dated Constructed Well Depth ft <br /> COMMENTS Ti4�IL D[—Ie,G//7 %:;P_'11A/ 277,Z2 <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes nfo By Cash emitted - Date Service Request# Invoice# Well ID# <br /> Yo 1,6z� 3b U-7-7 ZS <br /> EHD 43-06 8/01/16 f/ 1�, WELL/PUMP PERMIT <br />