WP0039080 - Laserfiche WebLink

Home Browse Search

�r WELL/PUMP PERMIT )SAN,JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 )YEAR FROM yDATE ISSUED 11OB ADDRESS?1c -I /,•rG�/1 �' �r�'�, —��((//�fJ, ��+�'��,p__y (/ Y/ZIP I ��`t 7 / ' `' / m CROSS STREET L—i) (^��i)I �) )� APN Z1 3 —O 7�YAKC:EL SIZE 33 ,�'�L�E APPLICATION# /� m OWNER NAME ✓�jrS 1 /(� PHONE U? � C,G OWNER ADDRESS �_— �1 ' Y/x�( I��OV c CITY/STATE/ZIP r�t, c CONTRACTOR —TZ r'rA( " //�i°e 1 1yC/� /L��O't j J'1 PHONE G] CONTRACTOR ADDRESS I 2— tr11/; J t^tS(rS'7ICITY/STATE/ZIP �1 1 �i ,l� 16' SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 11 C-61 IID-09 11 Other NUMBER �GG EXPIRATION DATE DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) 1.1 Dibromochloropropane(4392) Arsenic(4393) INTENDED USE ❑ Domestic/Private I I Irrigation/Agricultural ❑ Industrial L Water Quality Monitoring ;Soil Sampling/Characterization Public Water System If different from Owner. Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well I I Replacement Well ❑ Well Alteration/Modification ❑ Other C] Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings (Geotechnical_ �#of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair I 1 New Pump Ll P mp Replacement 11 Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method XMud Rotary ❑ Air Rotary Auger ❑ Cable Tool 1_' Push Point ❑ Other Proposed Well Depth 0 -sO ft Excavation in diameter I1 Open Bottom I I Gravel Pack/Gravel Size in diameter Conductor Casing in diameter / CondUcLor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched— Steel ❑ Plastic Stainless Steel I I Other Grout Seal Depth ft XNeat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water Bentonite(20%solids) ❑ Other _ Grout Placement Method Pumped ❑ Free Fall Other 4j_:n 2 1 Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor Ii Other ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in i I Christy Box ! Stove Pipe PUMP i Submersible,] Turbine I Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED f P/� 6 TITLE C�'�•G'��i 011 DATE ( W/9 7 ®bj 2,? tj r M 1+1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 DEPARTMENT USE ONLY Application Accepted By �/� � Date �� Area 40— Employee ID#kq� Grout Inspection By Date ❑ SPECIAt Well Permit Pump Inspection By Date ❑ WAIVER Received /J Soil Boring Inspection By A"i 6tfdDate Z ?z J Constructed Well Depth ft COMMENTS /_— PE Sc Received a Amount Date Permit/ Invoice# Well ID# Codes Info B ash Remitted Service Re uest# _444K 12 ) 1O�311_ EHD 43-06 8/01/16 WELL/PUMP PERMIT