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 A T,, CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ju...... ll 1`l 1 '\I - 1 0)j RV 011;0; Lrocal �.�✓1 1`� I m <br /> m <br /> CROSS STREET I � L �CCAC04 APN t 5-R`G 1 — PARCEL SIZE 1'71 LAND USE' <br /> IAPPLICATION <br /> V)L`OWNER NAME ___\D PHONE 90 C C#17 — I()')g <br /> ()')gQ <br /> OWNER ADDRESS I L-A CITY/STATE2PK61A C1 GoJ" -0 <br /> CONTRACTOR \_)C1l-fY PHONE 3/q — 2_779 <br /> CONTRACTOR ADDRESS CITY/STATE0P —6i C-181 IlW oAw <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISTAATEMP <br /> LICENSE A C-57 1,C-61 o J D-09 ❑Other NUMBER 3b EXPIRATION DATE J 1 �U <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)D Arsenic(4393) <br /> INTENDED USE DomestictPrivate C Irrigation/Agricultural -]Industrial C Water Quality Monitoring --!Soil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner: Water System Name Contact Nam or Phone Number <br /> I � <br /> TYPE OF WORK ),New Well Replacement Well Well AReration/Modification I Other <br /> D Monitoring Well(s) #of wells P Soil Boring(S) *of bonny i Geotechnical a of borings <br /> :,Out-Of-Service Well -:Out-Of-Service Well Renewal r Cross-Connection Repair <br /> New Pum D Pump Replacement ;Pump Repair h Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method AMud Rotary D Air Rotary �:Auger �Cable Tool E Push Point ❑ Other <br /> Proposed Well Depth3C5 It Excavation J:Z in diameter G Open Bottom A Gravel Pack/Gravel Size t/4- in diameter <br /> ,Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter�in Thickness/Gauge/ASTM Schad Cl 70C ❑Steel A Plastic r1 Stainless Steel !i Other <br /> Grout Seal Depth Q U ft D Neat Cement(94 Ib bag/5-10 gal water) ly-Sand Cement sack mixn gal water <br /> _;Bentonite(20%solids) Othe <br /> mr <br /> (:rn11t Pla n1 etcdx Pit uri n Fmf!Full r�fho PotWrrinnl/Cr nle atnr!n nl <br /> PEDESTAL Installed By riller -i Pump Contractor D Other <br /> Concrete Pedestal-i Dimensions:Width�ft Length It Thick in I I Christy Box D Stove Pipe <br /> PUMP )6.Submersible Ll Turbine D Other HP Pump Set ft Standing Water Level ISS 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 N <br /> WORKERS COMPENSATION LAWS. W <br /> MINIMLLM 48 HOU DVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 P <br /> SIGNED 'l'� �'� TITLE�.(,e �'r J 1 C 0+ DATE <br /> 9S <br /> iY <br /> N lolly <br /> X17 <br /> D <br /> G <br /> O <br /> ECE ENT <br /> 5 VED <br /> P 13 2018 <br /> DE PA TMENT4SE N <br /> El U' E OUN1Y <br /> Application Accepted B Date ( Area Employee ID# NTH DEPARTMENT <br /> Grout Inspection By `� l Date SPECIAL Well Permit <br /> Pump Inspection By �y 6Ak_4Qi SR \Date iJ 1 WAIVER Received <br /> Soil Boring_Inspection By Date Comstructed Well Depth ft <br /> ^OCOMMENTS two <br /> PE Sc Received Check#1 Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Re uest# Invoice# Well IN <br /> ( O l i.'2c.oU ( vl r <br /> ISO �1 S.t.OU <br /> 39 i <br /> EHD 43-06 revised 4/14/18 WELL/PUMP PERMIT <br />