Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLRMIT e CALL 20 953-77697 FOR IN C ONS PIRES 1 YEAR FRD DAT ISSUED <br /> JoeADDREss ca C"MP <br /> CROSS STREET N -I PARCEL S¢ '� LAND USE APS ATION# p <br /> OWNERNAME 1 (/,�(�//�t���� <br /> OWNER ADDRESS • //'tt, IV, G r ' CITY/STA IP <br /> CONTRACTOR 1jaylTzA- PHONE <br /> 11-20114 (la <br /> CONTRACTOR ADD RE S CITU/STATE I r(�o((]//��// <br /> SUBCONTRACTOR / HnNE <br /> SUBCONTRACTOR ADDRESS 1/ STATE///zl__P <br /> LICENSE C-57 -61 D-09 Other NUM6ER VV EXPIRATION DATE v <br /> DOMESTIC WF.LL S PLINe: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) �}'{ <br /> INTENDED USE V Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization 1 1 <br /> PublicblitWater System <br /> It different Water <br /> Owner: water System Name Contact Name or Phone Number <br /> TYPE Or WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) g( I at burins #of borings <br /> #of wells Soil Burin s g Geotechnical <br /> Out-Of-Service Well Out-Of-Servicg Vy11 Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth It Excavation :n diameter Open Bottom Gravel Pack/Gravel Size in diamet <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel . Other <br /> Grout Seal Depth it Neat Cement(941b bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant I Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> ncrete Pedestal Dimensions:Width ft L n th It Thiclt in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HPI 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 eetttz <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE C IFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> IM HOUR A E N CE REQUIR D EORlIQS�'ECTIt ONS�PL�EASE CALLOA 5 -76 <br /> SIGNED >tA 1/I�WJ�L1l� (� <br /> ^1 <br /> V 1 <br /> `W <br /> W <br /> CIN <br /> ITT III <br /> 0,4 it AR MENT 5 O <br /> Application Accepted By _ ate __`__w__ Area Employee ID#,A1!!j1 <br /> Grout Inspection By Dale _ PECIAL Well Permit <br /> Pump Inspection By WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth_ ft <br /> COMMENTS <br /> PE SC Received k#1 Amount Date Permit! Invoice# Weil ID# <br /> Co Info emitted Service Re ue t# <br /> I <br /> EHD43-06 R/O1116 WELL/PUMP PERMIT <br />