Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS � CITY/ZIP �i7� m <br /> CROSS STREET ir/i� J A�P�NJ��j ✓ PARCEL SIZE LAND USE AP/PL.IC�ATION# A <br /> o !y'h� /(J /� Z O�/f—�/ � <br /> cn <br /> OWNER NAME PHONE�,A • <br /> OWNER ADDRESS �nf/_�f` CITY/STATE/ZIP <br /> CONTRACTOR L' I PHONE <br /> c � <br /> CONTRACTOR ADDRESS / CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP All <br /> LICENSE -57 -61 El D-09 Ll Other NUMBER /�O EXPIRATION DATE _12Z�A <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE/1",Domestic/Private ElIrrigation/Agricultural ❑ Industrial I Water Quality Monitoring F1 Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump OumpReplacement D Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION PAYMEW <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter I i Open Bottom ❑ Gravel Pack/Gravel Size ter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft OCT 2 3 2018 <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement S'�J09d41j#q 6aai-water <br /> ejN11 Bentonite(20%solids) F1 Other HFA I--RONMENTAI Y <br /> Grout Placement Method ❑ Pumped ❑ Free Fall n Other ❑ Retardant/Accelerator(name) SEP rR ENT <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal F1 Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ubmersible❑ Turbine I I Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CE TIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE 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 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> SIGNED TITLE DATE <br /> i <br /> PARTMENT US �0N Y4a '� <br /> Application Accepted By Date J d Are /�/Employee ID# � <br /> Grout Inspection By Date F1 PECIAL Well Permit <br /> Pump Inspection By (kI �VO'� [�O OQ(—RX&U��A Date k0 ] �(�k b Ll WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Remitted S ice Re uest# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />