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 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ln <br /> �hu-� <br /> JOB ADDRESS 1 CITY/ZIP r m <br /> CROSS STREET l/�" A P N 4"61'- �Ci '�)Q PARCEL SIZE J I LAND USE APPLICATION#J� a <br /> m <br /> OWNER NAME PHONE �`'/ /✓ 2�J� <br /> OWNER ADDRESS 11A <br /> CITY/STATE/ZIP <br /> CONTRACTOR r I �I V �J PHONE <br /> CONTRACTOR ADDRESS QJ `�_ C) I lJL L- hhuQoub CITY/STATE/ZIP 5 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/,ZIP <br /> LICENSE 11C-57 [IC-61 ❑ D-09 j�Other NUMBER jl��rJEXPIRATION DATE — <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE c.,L 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 /> Pft <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical "kept <br /> V� <br /> Ll Well ❑ Out-Of-Service Well Renewal 11Cross-Connection Repair o <br /> t�New Pum F1 Pump Replacement ❑ Pum (IRe air Raise Well Casing <br /> WELL CONSTRUCTION SAN j <br /> Drilling Method 11 Mud Rotary Li Air Rotary Li Auger ❑ Cable Tool 11 Push Point Ll Other Lj_lVV�� <br /> Cow" <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel SizerOpARrn" meter <br /> El 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) C.l Sand Cement sack mix17 gal water <br /> ❑ Bentonite(20%solids) 7 Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller 1_1 Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ 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 /> IMUM 48 OUR/A,DV�ANCE NOTICE REQUIRED FORANSPECTIONS -PLEASE CALL (209) 95]3-7697 <br /> SIGNED t V TITLE DATE I <br /> D P RTMENT USE ONLY <br /> Application Accepted By Date l� Area Employee ID <br /> Grout Inspection By (fit- n Date [IPECIAL Well Permit <br /> Pump Inspection By � ���WV�`� Date Wrxt %k ���1 ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received ec Amount Date Permit/ Invoice# Well ID# <br /> Codes InfoRQ as Remitted Service Request# <br /> t _ � ) W " - 7 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />