WP0039516 - Laserfiche WebLink

Home Browse Search

.0 t"0.- I' III IffEo t ll�L�U WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-P97 F R INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED N JOB ADDRESS OCA �- CITY/ZIP m a CROSS STREET/ 1Lp' 14�P /�nN v' �O PARCEL SIZE _LAND USE AP^/P- 4. L�ICATIO)N# p OWNER NAME PHONE 1`- 4x �y y OWNER ADDRESS /e e— CITY/STATE/ZIP CONTRACTOR cl j �/ PHONE73 3 Y —q7%--:C CONTRACTOR ADDRESS ` CITY/STATE/ZIP [1 SUBCONTRACTOR a PHONE 77 j- !2__ ?9? SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE �-57 11C-61 11D-09 Ll Other NUMBER ^-1^/ / V6 EXPIRATION DATE DOMESTIC WELL SAMPLING: I General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) ! Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK '<New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair 49cUeW Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method 4::3ulud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other n Proposed Well Depth J 9>D ft Excavation 1'L in diameter ❑ Open Bottom [ravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel Plastic ❑ Stainless SteeJ� ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) S_�and Cement ��°J -s ack mi�Agal ter ❑ Bentonite(20%solids) ❑ Other PAl MEN Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ;driller ❑ Pump Contrao ❑ Other ❑ Concrete Pedestal []Dimensions:Width ft Length ft Thick in ❑ Christy Box pwtol -= 1 PUMP �C:::�ubmersible❑ Turbine ❑ Other HP Pump Set ft Standing Watq3/V@40AQUIN COUN I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCOr JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY RE CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 448 POU ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209)9553-7697 SIGNED ,/`C�G�A "f" TITLE V f�Jn/1��/ DATE ! C 2''1CWONG PWO94U ti Oath R—Tool Time iH Emsrorimveal HadM De.. C Google Maps ldE w_91EM-Otdlaok.., 2.Puce!V-HEALTH EHO d Paine Plus)dfwon9�10... 2.Business Portal Sign M iFCatS C-2012 F•2199,I:,WNRs cts: `GPQ4f�iiQ, v, a; � awr reavB ce,ILF uEw Pan la,. _ Adds— PD e0f lon� y h lamMim -� Hype �. . :IR.11 Y.� � � :land Yalw YA t .'..._ ...., .,, . .. � .._ -- • 0.m • E I __ ._- --. .: _ _- •. -.,, u.i.ilut,is.11Jx.=u.t+.Lu.l-If11E! t Sart B. ._-.--..-_ _,.,..__�—._ -- -.u..cod• _ '. .. _ .—_ E.•mpnon Code --- "'— -^:Y•ar Built B ' -- of Cod• ` __.. _ �_—�__.__�--._ :lot SM1.p• 0 Pr.SFJ i McNw aqu t. r�L>! T t - olattEm ll1—W-M�lllp.�_ Ix. E:=E ao_•E.. .,., � HDl>n.� - - ._ I�Mtl Plweo 218Mry 1R V -ne �-� �LtlNl.b: - ... ---- •••••• ••••.' IODI l —__ _— ._._ '• --.........__-" snow tlW area w.vl rasEDam PE SC Received Check#/ Amount Permit) Code Info B Cash Remitted Date Service Request# Invoice# Well ID# EHD 43-01, 8101/16 WELL/PUMP PERMIT