Laserfiche WebLink
N /- lg5-1F4 <br /> • WELL/PUMP PERMIT <br /> $AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT C L 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS U O CITY/ZIP J V m <br /> D <br /> CROSS STREET V APN D O S' - PARCEL SIZE O LAND USE APPLICATION# S <br /> Cn <br /> OWNER NAME 1 Aovwkwto PHONE Q 1, <br /> / /I c? <br /> OWNER ADDRESS a_ Q " CITY/STAT ZIP � �C'�,1ry / .�lf' L <br /> CONTRACTOR 1XZQ �"_—" "�,` PHONE Z•L../q —�d 5— ✓V5_ <br /> CONTRACTOR ADDRESS 1 " y' _cLuV LJA' t� <br /> � ITY/$TATE/ZIP ��(/` V� ! c� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP ( I I <br /> LICENSE C-57 El C-61 11D-09 11U Other NUMBER EXPIRATION DATE✓—/ 3 1 1 I 9 t <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ 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 ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings /44 Geotechnical 13 #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary *'Auger ❑ Cable Tool I I Push Point ❑ Other <br /> Proposed Well Depth 10`I — ft Excavation U 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 ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped II Free Fall ❑ Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor CI Other <br /> ❑ Concrete Pedestal []Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine I I 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�NUM 4P HO ��D�I ,NCE NOTICE REQUIRED FOR SPE TIONS - LEASE CALL (209) 953-7 97 <br /> AA <br /> SIGNED //�AAYA �l�Q/�/ TITLE DATE � <br /> 0,LQ <br /> H O N <br /> RM <br /> DEPA TMENTU E ONLY <br /> Application Accepted By to <br /> ( F? Area l / Employee ID#1VAN <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By 9 IF Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received eck# Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Ua-s h Remitted Service Request# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />