Laserfiche WebLink
WELUPUMP PERMIT �✓ <br /> SA'.,!JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE P RMIT } CALL 209 953-76697 FO SPECTIONS ,EXPIRES 1YEAR FROM DATE ISSUED <br /> .OB ADDRESS / l IS'GCITY/ZIP C ZA I./ I� m <br /> CROSS STREET 14-1 IAPNC) <br /> .(90 /7 PARCEL SIZE w LAND USE APPLICATION## cn <br /> TOWNER NAME (J � �+ 1JJ'i 5c, 14 PHONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> u <br /> CONTRACTOR / <br /> � �L`1 PHONE �� [ y y a <br /> CONTRACTOR ADDRESS <br /> �/ /.�.� l Ot CITY/STATE/ZIP ZZ 60"a `& <br /> SUBCONTRACTOR e �f PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP 6-11' <br /> LICENSE ,eC-57 I I C-61 I D-09 n Other NUMBER �2 ')3 9-f <br /> EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private I I Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK -i New Well CI Replacement Well F1 Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(S) If of borings Ll Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal a Cross-Connection Repair <br /> ew Pump I 1 Pump Replacement F1 Pump Repair LI Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method>LMud Rotary ❑ Air Rotary a Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth L J ft Excavation I ) in diameter ❑ Open Bottom , cGravel Pack/Gravel Size in diameter <br /> l I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6- in Thickness/Gauge/ASTM Sched 'L-?D— ❑ Steel I.),Olastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth_2!=2_b0 Ift ❑ Neat Cement(94 lb bag/5-10 gal water) eSand Cement J sack mix17 gal water <br /> LI Bentonite(20%solids) ❑ Other <br /> Grout Placement Method - umped F1 Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ,<'Driller ❑ Pump Contractor LI Other <br /> ❑ Concrete Pedestal Ll Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP 4, 6ubmersiblel I Turbine I Other HP_ Pump Set 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 /> .0A1� INv 1. V ORDI AIN ES, STATE LA <br /> �3, AN <br /> G RLL`- -N` REGULATIONS. IALSvCERTIFY THAT Ji'r REQUIRED LICENSE <br /> 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 /> MINIMUM 2244 HOU ADV NCE NOTICE REQUIRED FOR-INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED <br /> r TITLE DATE _ <br /> ti <br /> IF I <br /> Q IL H <br /> U� <br /> A7fPRTMENT U E NLY <br /> Application Accepted By Date �fArea Employee ID#� <br /> Grout Inspersion By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By v Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMM,,NTS � /A/ I r <br /> PE SC Received Check#/ Amount Permit/ <br /> Code Info B Cash Remitted Date Service Request# Invoice# Well ID# <br /> 5Z. <br /> 63P150'315�-ql r <br /> EHD43-06 8/01/16 WELL/PUMP PERMIT <br />