WP0039624 - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 11 . 5. � aVcncc _ ;0 rn JOB ADDRESS /�_ _) rCITY/ZIP6, dl�tSY\_ TES� � �O _ m 1_ Q D CROSS STREET `.O�.y1�Y4 t(j r IVJl. APN 2 Z9 -04 D• D Ll PARCEL SIZE2� LAND USE APPLICATION# A rn OWNER NAME R,ODr ✓ 1 ��i �� rIY�OD 1 n PHONE 1 51D IAt� C .S}. OWNER ADDRESSUV�14 h \ �Ca L i r C l P. CITY/STATE/ZIP SS 0 0. 0 r_1 C 1', g 6 3 W CONTRACTOR `\ I PHONE L- CITY/STATE/ZIP ✓ 7 �(�� (�^�L� CONTRACTOR ADDRESS ` CITY/STATE/ZIP'• LD A c S� 1 `� "7 ✓�/� SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY//STATE/ZIP ` LICENSE C 57 1 1 C-61 I I D-09 I I Other NUMBER Z 1 O EXPIRATION DATE 5 1 2,O DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic(4393) INTENDED USEDomestic/Private I Irrigation/Agricultural '1 Industrial 11Water Quality Monitoring Il Soil Sampling/Characters Ion Y1 Public Water System R �yAnn", If different from Owner. Water System Name Contact Name or Phone Nber um1"itl 1 VC TYPE OF WORK New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other borings f b ❑ s Monitoring Well ❑ #of b Well(s) #of wells Soil Boring(s) I_I Geotechnical � �� oy� ❑ New 11 Out-Of-Service fWPum Replacement ❑ Pump Repair l D ie Well Renewal El❑ Rase Well CasCross-Connection Repair SAng E J 01 ik,— /ri,,_v C i WELL CONSTRUCTION T H DEpAR SENT Drilling Method 1 Mud Rotary ❑ Air Rotary 11 Auger f' Cable Tool i 1 Push Point C1 Other Proposed Well Depth2.5 0ft Excavation 14 in diameter I I Open Bottom /- Gravel Pack/Gravel Size in diameter I Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched;=l p I I Steel lastic Stainless Steel !-I Other Grout Seal Depth �O O ft ❑ Neat Cement(94 lb bag/5-10 gal water) I Sand Cement sack mix/7 gal water entonite(20%solids) ❑ Other Grout Placement Method Pumped ❑ Free Fall Other Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller Wmp Contractor ❑ Other Cl Concrete Pedestal Cl Dimensions:Width ft Length ft Thick in ❑ Christy Box I Stove Pipe PUMP I I Submersible❑ Turbine I! Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 48 HOUR ADVANCE NOTICE REQU OR�/I/ 5JNSPECTIONS - PLEASE CALL (209) 9953-76997 4 SIGNED TLE . DATE — I V�� J DEPARTMENT USE ONLY Application Accepted By pp ��t� Date (j Area ,'I-ployee ID# Sl�� Grout Inspection By MJF '1Lr" Date _0 ] SPECIAL Well Permit Pump Inspection By Date 1-1 WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS , PE SC Received Amount Date Permit/ Invoice# Well ID# Codes Info B asb Remitted Service Request# 14, 10 CO-20.0 V`jP00 �0. 00?260 Z 16ot — EHD 43-06 6/01/16 WELL/PUMP PERMIT