Laserfiche WebLink
WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT C p CALL ZpU9 95J -/b9! FOR INSPECTIONS <fytAVIKtb 'I YEAR FROM DATE ISSUED <br />JOB ADDRESSy��c S`Frj C�G+'Gl %Ll�i(.c! CITY/ZIP <br />f� _ <br />CROSS STREET L/L/(� C Ceell- Vr- A{PNN- 3 J t '1, PARCEL SIZEd.d-3 LAND USE APPLICATION # <br />OWNER NAME �j//V y ` 1 PHONE <br />OWNER ADDRESS ��CITY/STATE/ZIP <br />CONTRACTOR yCe% L SSec- PHONE �7LOq - 3/ <br />1 � -3A'l <br />CONTRACTOR ADDRESS qC`Z .TP,- iVr1H CITY/STATE/ZIPyLHI e.-lf `% s�yr <br />SUBCONTRACTOR Su Yl'u PHONE <br />SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br />LICENSE 'C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER ! O EXPIRATION DATE _ <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring XSoil 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 ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings I�IGeotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New rump u rump Kepiacemenr ❑ rump Kepalr a raise vven easing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary WAuger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth4 K- ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />in diameter) <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched I I Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft 1,U Neat Cement (94 lb 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 [ I Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor I Other <br />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 />MI U 48 HQU NCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED �� TITLE�Jeefec/l%#Ii �4/p��!,Ll /"IG'✓Ir.1R+-DATE <br />AlP RTMENT USE ONLY <br />Application Accepted By Date <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />T <br />m <br />m <br />D <br />0 <br />v <br />X <br />m <br />co <br />co <br />Area - Employee ID#� <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth ft <br />PE Sc Received Che Amount <br />odes Info B Cash emitted <br />Permit/ <br />Date Service Re uest # Invoice # Well ID# <br />r� <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />