Laserfiche WebLink
1 <br /> WELL/PUMP PERMIT P f t• <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH G=PARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7097 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> cn <br /> JOB ADDRESS CITY/ZIP Gi / m <br /> +^ D <br /> CROSS STREET / APN 010 PARCEL SIZE �(�LAND USE <br /> �APPLICATION <br /> 7�# j A <br /> OWNER NAME /� J I_"�� T � PHONE/, 4/ `J �/ ✓ cn <br /> OWNER ADDRESS / n © ®� CITY/STATE/ZIP <br /> CONTRACTOR � '� PHONE 3 3Y- <br /> CONTRACTOR <br /> Y`CONTRACTOR ADDRESS d CITY/STATE/ZIP -� <br /> SUBCONTRACTOR 9 Kf'tozC PHONE J✓� � <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 [1 C-61 [ID-09 I Other NUMBER //��EXPIRATION DATE `�`1el, <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) 1 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 IJ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> [I Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings u Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> IQ�New Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method %;,.fdlud Rotary 7 Air Rotary 1_I Auger ❑ Cable Tool I I Push Point LI Other <br /> Proposed Well Depth ft Excavation in diameter 1-1 Open Bottom ravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter �► in Thickness/Gauge/ASTM Sched — ❑ Steel �'lastic ❑ Stainle s Steel U Other <br /> Grout Seal Depth / ft 11Neat Cement(94 lb bag/5-10 gal water) Sand Cement to; sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor I Other <br /> ❑ Concrete Pedestal F1 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 /> MINI LIMM224 HO R ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 <br /> / ,/^ <br /> SIGNEDC" ly�� TITLE ��!`s� DATE � ' <br /> f <br /> S <br /> A4JOAUlfilCOU <br /> 7A USE ONLY <br /> Ma c <br /> Application Accepted By E Date Area Employee ID# <br /> Grout Inspection By Date Ll SPECIAL Well Permit <br /> Pump Inspection By Date�` I WAIVER R@C@IVed <br /> Soil Boring Inspection By _._ Date_ Cuostructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Cod Info B Cash emitted Date Service Request# Invoice# Well ID# <br /> ski P CC <br /> 14 d w t�38 <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />