Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> �1 / a <br /> JOB ADDRESS /�� O 1:*4�s nV � CITV21'P !O t��J'O✓ �myj <br /> CROSS STREET '` I-eg rk- ^'(d_* APN 1! 7 00160PARCEL SIZE '• a LAND USE APPLICATION <br /> <br /> <br /> OWNER ADDRESS 6 SY J a' � A-jV"� A1117P ANAMPC C 0 -;P-,yC j <br /> CONTRACTOR e 0 A.0/.✓ STl'y bw IL' PHONE(1W-) <br /> CONTRACTOR ADDRESS YS 0 O 4 F,�i�•s-�v ��`- CITY/STATE/ZIP d.7•b 4%�r T4s✓ �U ��z <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CIM/STATE2,P A/, <br /> LICENSE 5 G57 -61 ❑D-09 _ Other NUMBER ,Q <br /> 79&3f EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:-General Mineral/Coliform Bacteria(4391)-Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Q Domestic/Private Irrigation/Agricultural -:Industrial 7,Water Quality Monitoring Soil Sampling/Characterization <br /> P Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK o New Well ❑Replacement Well _I Well Alteration/Modification -j Other A14c-,/ CI�G� .S4C;fk <br /> i Monitoring Well(s) #of wells 7 Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> rl Out-Of-Service Well -i Out-Of-Service Well Renewal r Cross-Connection Repair <br /> ❑New Pump i. Pump Replacement ti Pump Repair 11 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method r-Mud Rotaff r Air Rotary - Auger - Cable Tool -Push Point r Other <br /> Proposed Well Depth ft Excavation In diameter L Open Bottom i7 Gravel Pack/Gravel Size In diameter <br /> U Conductor Casing In diameter I Conductor Casing Depth ft <br /> Well Casing Diameter r In Thickness/Gauge/ASTM Schad Steel ❑Plastic ❑Stainless Steel j Other <br /> Grout Seal Depth ft L Neat Cement(94 Ib bagl5-10 gal water) u Sand Cement sack mix/7 gal water <br /> Lj Bentonite(20%solids) L Other <br /> Grout Placement Method - Pumped - Free Fall F Other [: Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller _ Pump Contractor Other <br /> Concrete Pedestal 1:Dimensions:Width ft Length ft Thick in i Christy Box - Stove Plpe <br /> PUMP Submersible Turbine Other HP / X 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 /> MINIMUM 4 OTICE REQUIRED FOR INSPECTIONS_-PLEASE CALL(209)953-7697 <br /> SIGNED H URADVANCE NTITLE ©/"IS /s'yf�A�' DATE <br /> YMENT <br /> RECEIVED <br /> 2 5 2019 <br /> a IC QUIN COUNTY <br /> ODARONMENTAL <br /> DEPARTMENT <br /> AR <br /> ENT U�Y /I <br /> Application Accepted By ate � Amo_, Employee ID#�!=���k1� <br /> Grout Inspection By Date 7 PECIAL Well Permit <br /> Pump Inspection By KWQ4!� �y 0 r p�,�Y�Data O A k 10 �U"P� ❑ WAIVER Received <br /> Sal Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received eck#/ Amount Date Permit/ Invoice# Well IDN <br /> Codes Info Remitted Service Re Uest# <br /> L7 <br /> EHD 43-08 revised 4/14/78 WELL/PUMP PERMIT <br />