Laserfiche WebLink
WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN -REFUNDABLE PERMIT <br />Application Accepted By % <br />GALL ZUy yb3-(b`Uf FOR INSPECTIONS r_ArIKCJ -1 TEAK I-KUM UAIt IbbutIJ <br />JOB ADDRESS �1 <br />CROSS STREET l/11Vy <br />Date <br />j� <br />l <br />k Q %. J�% / CITY//ZIP �sfp6 hn � -:Z ),5 <br />AXP/N�P,�'[ / —0/ O _/ � PARCEL SIZE / LAND USE APPLICATION #%�i <br />`f� p '\ j, <br />o ef- <br />jr� <br />I�� <br />OWNER NAME <br />K �n <br />A6 <br />a m's 6 t � PHONE �� / J A- -7Q� <br />OWNER ADDRESS <br />h 90---4 4 <br />CITY/STATE/ZIP Fal D &►'d/�, C 2(e0 a3 <br />CONTRACTOR <br />M oorman'5 <br />wA /Y LS <br />I O <br />tt it � l PHONE 9 Uclr q3) — I I D <br />CONTRACTOR ADDRESS 2-12-0 <br />WI <br />'()%U <br />I C 0,'6 CITY/STATE/ZIPS C .4 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE j (C-57 ❑ C-61 ❑ D-09 1I Other <br />PHONE�� / <br />CITY/STATE/ZIP 1 4 <br />^ <br />NUMBER �_/� EXPIRATION DATE <br />FEBM <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE ;(Domestic/Private ❑ Irrigation/Agricultural 1-1 Industrial ❑ Water Quality Monitoring ❑ 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 Ll 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 V Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point LI Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom Ll Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) 11 Sand Cement sack mix17 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other I i Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal []Dimensions: Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br />PUMP XSubmersible❑ Turbine ❑ Other HP 1 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 />SIGNED <br />OTICE REQUIRED F0� I P <br />TITLE i <br />I1 <br />DEIAARTMENT USE ONLY <br />t <br />Application Accepted By % <br />Datellkr�h-e <br />Grout Inspection By <br />Date <br />Pump Inspection By �I�p�rJ ��t 11 �iT I <br />{� <br />Date 2 2 U <br />Soil Boring Inspection By <br />Date <br />COMMENTS <br />NS9 - PLEASE CALL (209) 53-76 7 - <br />/ DATE <br />Area Employee ID#� <br />f__1 SPECIAL Well Permit <br />P WAIVER Received <br />Constructed Well Depth <br />ft <br />T <br />m <br />0 <br />0 <br />o <br />m <br />m <br />En <br />PE SC Received heck#/ <br />Codes Info B <br />Amount Date Permit/ Invoice # Well ID# <br />Remitted Service Request # <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />