Laserfiche WebLink
f f <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> r <br /> JOB ADDRESS J 0 L Ivo r-5' CITYZP'5to t tjo V-) r m <br /> p� 11� �7 Q D <br /> CROSS STREET_N �� APN t./ `' (—LO-- <br /> ')PARCEL SIZED r LAND USE APPLICATION# -tet/� / o <br /> ' LI -1(a 10 m <br /> OWNER NAME /'� Q �y" �iJ r, - yP.HON�����/I��L' rn. <br /> OWNER ADDRESS ( L)M T`'5 lIl}Gr CITY/STATE/ZIP <br /> CONTRACTOR \19�w1 ' PHONE CXr•-)� r��C(1 <br /> CONTRACTOR ADDRESS I ,-(% CITY/STATE/ZIP til L ( ✓tL? L, <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS ICITYIS,.,TTAATTE/ZIP L.� f <br /> LICENSE C-57 -i C-61 .. D-09 Other NUMBER � <br /> 72- tO EXPIRATION DATE L--3 —7-0 0 <br /> DOMESTIC WELL SAMPLING:_General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)� Arsenic(4393) <br /> INTENDED USE DomestirtPdvate 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) I #of bodrgs Geotechnical #of borings <br /> I Out-Of-Service Well 'Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum _ Pump Replacement i)Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMud Rotary 1 Air Rotary i Auger Qi Cable Tool Push Point Other <br /> Proposed Well Depth b ft Excavation 8 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched i i Steel i Plastic !Stainless Steel Other <br /> Grout Seal Depth�_ft Neal Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) i Other <br /> Grout Placement Method Pumped Free Fall Other i Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor F 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 /> MIMMW 48 HOUR ADV*aCE NOTICE REQUIRED FOR INSRIECT ONS-PLEASE CALL(209)953-76(97 Q <br /> SIGNED TITLE �J l �V Vex 1 DATE <br /> ENT <br /> IVED <br /> 2018 <br /> COUNTY <br /> ENTAL <br /> RTMENT <br /> PA MENT US O Y (/�� �y�{� <br /> Application Accepted By ' ate Area -1 Employee ID#18 . —! <br /> Grout Inspection By Date PECIAL We11 Permit <br /> Pump Inspection By / Date WAIVER Received <br /> Soil Boring Inspection By�1S Zee+j 4 Date�V /�� Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received rhecli Amount Date Permit/ Invoice# Well ION <br /> Codes Info Remitted Service Re uest# <br /> t <br /> EHD 43-06 revised 4/14/18 <br /> WELL/PUMP PERMIT <br />