Laserfiche WebLink
IA.)% YZ <br /> "n WELL/PUMP PERMIT <br /> " <br /> SAN.JOAdJIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 09 L953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS /l J /� CITY/ZIP © % m <br /> CROSS STREET U APN PARCEL SIZE "LAND USE APPLICATION# <br /> ." G��i � muIDL�LOWNER NAME PHONEo <br /> /J'�� /��/} or <br /> OWNER ADDRESS n e V CITY/STATE/ZIP I/�M�� [� �jh <br /> CONTRACTOR &-A �j o's%y 1 — PHONE 3 /L z 7� <br /> CONTRACTOR ADDRESS (� CITY/STATE/ZIP!,� 1ebA76&,a-Lr <br /> SUBCONTRACTOR PHONE "�t <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 ElC-61 [ID-09 ❑Other NUMBER( '7-VS EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:UGeneral Mineral/Coliform Bacteria (4391)MDibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Ll Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water bystem Name -------Umnlact Name or Phone Number <br /> TYPE OF WORK New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring( ) ❑Geotechnical s #of borings #of borings <br /> ❑Out-Of-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 ft Excavation 12— in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6' in Thickness/Gauge/ASTM Schad ❑Steel .'Plastic El Stainless Steel ❑Other <br /> Grout Seal Depth 2_3o ft ❑Neat Cement(94 Ib bag/5-10 gal water) and Cement_ - sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method ri�rPbmped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By 190riller ❑Pump Contractor ❑ Other <br /> E]Concrete Pedestal dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP 155ubmersible❑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 /> MINI M 4 H//UR ADVANCE NOTICE REQUIRED FOAR/ INSPECTIONS - PLEASE CALL (209) 953-7697 7 <br /> SIGNED =17I/LVl TITLE V W I✓�1- DATE <br /> AX <br /> Ju <br /> S /y <br /> I// N O <br /> L <br /> DE ARTMENT SE /O LY <br /> Application Accepted By a Date r Area Employee ID# i <br /> Grout Inspection Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date `l ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check Amount Permit/ <br /> Code fo 'tt <br /> ash emed Date Service Request# Invoice# Well ID# <br /> d 2 Il 1Zw 76 VVI00o, (w� <br /> es!yrj 21,311 U-7 l 1960 <br /> I 0_71 2?_ 03 Dqtp <br /> EHD 43-06 6/01/16 WELL/PUMP PERMIT <br />