WP0038643 - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 9� �5^3-/7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS %� + 3 /� CITY/ZIP m �ry D CROSS STREET t J../��/[� j/� APN // � F PARCEL SIZE y AND USE APPLICATION#J J OWNER NAME /QznJ��1 t PHONE?ocn cn OWNER ADDRESS / m e 1 CITY/STATE/ZIP �f CONTRACTOR 'P'yy' /`I,�i�Z�`C> / �PHONE CONTRACTOR ADDRESSO !Z�d `2 R CITY/STATE/ZIP SUBCONTRACTOR c 't�'l ( �rt►S'S pe,•v. PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE Af;; -57 El C-61 [I D-09 El Other NUMBER EXPIRATION DATE DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) INTENDED USE 11�7Domestic/Private ❑Irrigation/Agricultural [:]Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name (;ontact Name or Phone Number TYPE OF WORK *%Aew Well El Replacement Well ❑Well Alteration/Modification E]Other #of borings #of borings El Monitoring Well(s) #of wells ❑Soil Boring(s) ❑Geotechnical F]Out-Of-Service Well ❑Out-Of-Service Well Renewal E]Cross-Connection Repair ew Pump ❑Pump Replacement ❑Pump Repair [:]Raise Well Casing WELL CONSTRUC ION Drilling Metho4c:rMud Rotary E]Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑ Other Proposed Well Depth�_ft Excavation I in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel >01astic ❑Stainless Steel ❑Other Grout Seal Depth / ft ❑Neat Cement(94 Ib bag/5-10 gal water) 51§and Cement sack mix/7 gal water ❑Bentonite(20%solids) ❑Other Grout Placement Method—knumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By riller []Pump Contractor ❑ Other [:]Concrete Pedestal dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level ft 1 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. MI=UR UR DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697/ SIGNED ftp- TITLE (i/(jj DATE J /N 4f4- r--AF T DEPARTMENT USE O LY Application Accepted By Date Area Employee ID# Grout Inspection By '1�S Date Al' ❑ 4P ECI L Well Permit Pump Inspection By Kk_V—Or1 Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth 3 ft COMMENTS PE SC Received Check Amount Permit/ o fo By-, ash emitted Date Service Request# Invoice# Well ID# ,I EHD 43-06 8/01116 WELL/PUMP PERMIT