Laserfiche WebLink
WELL/PUMP PERMIT <br /> SrrN JOAQU�ACOUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALIr(2021953-7697 FOR INSPECTIONS E PIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS {' CITY/ZIP <br /> CROSS STREET APN ' Q�` / PARCEL SIZE AND USE APPLICATION# _ o <br /> cn <br /> OWNER NAMEP HONE to <br /> OWNER ADDRESS N. CITY/STATE/ZIP <br /> CONTRACTOR �` / �{�—Z� Q� �jl�jt�( PHONE c/ <br /> J y- L <br /> CONTRACTOR ADDRESS 3 l7J f ` � CITY/STATE/ZIPC/ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C 57 ❑C-61 ❑D-09 F1 Other NUMBER S f L ✓K EXPIRATION DATE 1� <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring [-]Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner. Water System Name Uontact 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 /> L]Out-Cf-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ew Pump ❑Pump Replacement [-]Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method'<Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth j ft Excavation �?„ in diameter E]Open Bottom Gravel Pack/Gravel Size in diameter <br /> [-]Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter-16- in Thickness/Gauge/ASTM Sched ❑Steel �lastic E]Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) �P8and Cement l(�. sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Methodo�KPumped ❑Free Fall El Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ,Kpriller ❑Pump Contractor ❑ Other <br /> -- <br /> El Concrete Pedestal dimensions:Width , ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible❑Turbine ❑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 /> 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 /> MINIIV �4 H�Q/UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS F- 7- 0 <br /> ECTIONS - PLEASE CALL (209) 953-J7697 <br /> SIGNED lJ t�(s+— TITLE O(--Jx'&— DATE — C— 0 <br /> r � <br /> 00 <br /> UZ <br /> 3 lix 5 <br /> t <br /> fP J <br /> ;7k <br /> TFr <br /> DE ARTMENT USE ONLY <br /> Application Accepted B DateArea Waq Employee ID#���=�C�1 <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constr cted Well Depth ft <br /> CO MENTS 1 t G <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> pQqgq. Info By Cash Remitted Service Request# <br /> :14451" (6/7/17 <br /> ` <br /> EHD 4.i-06 8/01/10 WELL/PUMP PERMIT <br />