WP0037899 - Laserfiche WebLink

Home Browse Search

} WELL/PUMP PERMIT SAN JGAQUIN COI, ITY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 'NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED f� JOB ADDRESS / �I ai pit CITY/ZIP m CROSS STREET 4 k-kl APN U l� PARCEL SIZE I S, 5 LAND USE APPLICATION# v cn OWNER NAME 13 6 6 r PHONE L Uf L JJ OWNER ADDRESS -TA / _ CITY/STATE/ZIP CONTRACTOR _3 r. Piz:,� 6 PHONE 3 3 y- /J CONTRACTOR ADDRESS �� n�(�tb�i 1 D? CITY/STATE/ZIP SUBCONTRACTOR 0'---A-, f T}f( �/��XLf L,,.A PHONE 4 �7 SUBCONTRACTOR ADDRESS rn CITY/STATE/ZIP LICENSE C-57 11 C-61 I I D-09 ❑ Other NUMBE17_ZZ6!-S: EXPIRATION DATE —� DOMESTIC WELL SAMPLING: ;XGeneral Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural L.I Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization 1 Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK <New Well ❑ Replacement Well ❑ Well Alteration/Modification I Other I 1 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings / I I Out-Of-Service Well 11 Out-Of-Service Well Renewal F1 Cross-Connection Repair ;1i4eW Pum ❑ Pump Replacement ❑ Pump Repair [I Raise Weil Casing WELL CONSTRUCTION Drilling Method< Iud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool a Push Point ❑ Other Proposed Well Depth _ ft Excavation X in diameter LI Open Bottom <Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Schedl--10'D ❑ Steel,><Plastic ❑ Stainless Steel ❑ Other Grout Seal Dept �ft CI Neat Cement(94 Ib bag/5-10 gal water) -<Sand Cement /0.`� sack mix/7 gal water I I Bentonite(20%solids) Ll Other Grout Placement Method<Pumped 11 Free Fall U Other f I Retardant/Accelerator(name) PEDESTAL Installed By%.4briller I I Pump Contracto Ll Other I Concrete Pedestal ❑Dimensions Width ft Length ft Thick in ❑ Christy Box I 1 Stove Pipe PUMP +Q Submersible F1 Turbine 11 Other HP Pump Set ft Standing Water Level 0 ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINI UM 24 HO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 SIGNED A 0101 TITLE ,J/.c DATit- W w �\ Irk I tee 1 u p O a G f" A R T IVI E i• ��]]U 3 L V i4 L`I Application Accepted By Date' Tom`- I — I Area — Employee ID# W U n 02x �1YI(e�S� 2'�� I D SPECIAL Well Permit Grout Inspection By _ Pump Inspection By CW Date 0 11 WAIVER Received Soil Boring Inspect'-on By n n� �Date Constr cted Well Depth ft COMMENTS 7)7 — PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info Cash Remittej Service Re uest# y 3 l3 2 �jt 2 t I(, ��J Y`7f 2111le W 00 3-+ 9`I 43OSS) v3Sigt 2 ► II W o -: o I EHC 43-06 8/01/16 WELL/PUMP PERMIT