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 CALL 953-7697 FOR INSPECTIONS �EXPIRES 'I YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP <br /> o <br /> 20�-23o I <br /> CROSS STREET PN ( PARCEL SIZEO_LAND USE A PLICATION# p <br /> �7 l ;0 <br /> OWNER NAME vy <br /> C. PHONE / vi <br /> OWNER ADDRESS CITY/STATE/ZIP E- l <br /> Dy <br /> CONTRACTOR /.• r `.G PHO <br /> CONTRACTOR ADDRESS - / CITYISTATE/ZIP /U/ /X__/(_,/ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBS �I EXPIRATION DAT L/ <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) i i Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/CharacterizationqV <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 /> Ll Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings 11 Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pum ❑ Pump Replacement 1l Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodxMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool 11 Push Point ❑ Other <br /> Proposed Well Depth 'moi ft Excavation 42-e I/ in diameter I 1 Open Bottom XGravel Pack/Gravel Size, in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 7�o InThickness/Gauge/ASTM Sched ' ElSteel Plastic LI Stainless Steel I1 Other <br /> Grout Seal Depth 2`— ---- ft I 1 Neat Cement(94 Ib bag/5-10/gal wafer) ❑ Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) 1_I Other <br /> Grout Placement Method X Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller II Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal El Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine I1 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 /> MINI 2.4 HOUR ADVANCE NOTICE REQUIRED FOR TSPECTIONS -PLEASE CALL (209) 953-7699!7 / L <br /> SIGNED TITLE �/ DATE �i <br /> 1 <br /> U <br /> � E N <br /> E <br /> N <br /> G� Ti I lil L IY 1 J L IY L i <br /> Application Accepted By Date Z7 Area Employee ID <br /> Grout Inspection By Date / ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Receivedheck#/ Amount Date Permit/ Invoice# Well ID# <br /> Cod I B Cash Remitted Service Re uest# <br /> 5 3q 2�7t% <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />