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 EXPI ES 1 YEAR FROM <br /> DATE ISSUED <br /> JOB ADDRESS Is � � i/�Y CrrY/ZIP <br /> J/y�� Z I J�(� D <br /> CROSS STREET M I I /1 APN O�Q-�+ L V PARCEL SIZE LAND USE APPLICATION# A <br /> m <br /> OWNER NAME PHONE ti <br /> OWNER ADDRESS tf{p .+ CRY/STATE/ZIP <br /> t-I <br /> CONTRACTOR •" //` PHONE -1 k—I J`( <br /> CONTRACTOR ADDRESS V �1��/ CRY/STATE/ZIP <br /> SUBCONTRACTOR Q rt ',C ,/ PHONE `'" !� Q <br /> SUBCONTRACTOR ADDRESS ✓ hf <br /> (� D CRYISTATE/ZIP W T 'r(.� �J��` <br /> LICENSE V C-57 C C-61 ❑D-09 LIOther NUMBER 146 qg n- EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:n General Mineral/Coliform Bacteria(4391)n Dibromochloropropane(4392)n Arsenic(4393) <br /> INTENDED USE 7 Domestic/Private ❑Irrigation/Agricultural F Industrial n Water Quality Monitoring V Soil Sampling/Characterization <br /> L Public Water System <br /> If different from Owner.. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK F New Well n Replacement Well E Well Alteration/Modification E Other <br /> L Monitoring Well(s) #Of wells L Soil Boring(s) #of borings VGeotechnical=11 of borings <br /> E Out-Of-Service Well F Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> n New Pum n Pump Replacement n Pump Repair n Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method'/Mud Rotary n Air Rotary %I Auger n Cable Tool n Push Point n Other <br /> Proposed Well Depth 5—SO ft Excavation in diameter L Open Bottom L Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched L Steel C Plastic 7 Stainless Steel n Other <br /> Grout Seal Depth it 4 Neat Cement(94 lbba -10 gal wafer) E Sand Cement sack mix17 gal water <br /> D Bentonite(20%solids) ❑Other <br /> Grout Placement Method4Pumped F Free Fall 7 Other 7 Retardant/Accelerator(name) <br /> PEDESTAL Installed By i I Driller i Pump Contractor I Other <br /> Concrete Pedestal Ll Dimensions:Width ft Length ft Thick in D Christy Box D Stove Pipe <br /> PUMP n Submersibles Turbine n 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 /> MINIM M 4 HOUR ADVANCE NOTICE REQUIRED FOR I CTIIIOOINCS-PLEASE CALL(209)953-7/69 t <br /> SIGNED ' TITLECd� 1. "J��C.O� DATE `� <br /> Y <br /> U 9 2®19 <br /> Q�,N <br /> FAgR��N�' <br /> NT <br /> D"T E 6 NLY(j l/( <br /> Application Accepted By Date / Area I Employee D#­V-4 <br /> Grout Inspection B Date 1 SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date V Constructed Well Depth It <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted vice Request# <br /> f- 1Vj <br /> EHD 43-06 revised 4/14/18 �/� _ / G // -/`-/LTJ WELL)PUMP PERMIT <br />