Laserfiche WebLink
t '1 Irl r <br /> WELL/PUMP PERMIT <br /> "SAN JOAJUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTO 0 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS pE"XPIRES 1 YEAR�F/ROM DATE ISSUED <br /> JOB ADDRESS <br /> S �-CJS/ (�(., L, r//1 n e CITYIZIP /7'�/y e m <br /> 1 <br /> �J D <br /> CROSS STREET 0.J� �I�, I tS wrSr S C�1APN�z .`- J-22_-02L PARCEL SIZE I-S LAND USE APPLICATION# A <br /> 7CCll 7 En <br /> OWNER NAME <br /> 1 of'c� r PHONE S O '2, 9 7 1/ 9 v, <br /> qq Q I /jJ 4 <br /> OWNER ADDRESS Oa 1 n CITY/STATE/ZIP�(/�dc!( CA 933 y <br /> CONTRACTOR C I/ y PH/O�N/IE z�/ 7 6 5 6 9'2 6 <br /> CONTRACTOR ADDRESS CSU J/ \ U CITY/STATE/ZIP y' tf K`bC C,- <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP{} <br /> LICENSE NK57 E:]C-6 F-1D-09 ❑Other NUMBER <br /> S - <br /> Y���� I O EXPIRATION DATE 31- f <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391)❑Dibromoch;oropropane (4392)❑Arsenic(4393) <br /> INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil SamplingiCharacterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK f�New Well ❑Replacement Well ❑Well Alteration/Modification [:1 Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical_ #of borings <br /> F-1 Out-Of-Service Well E]Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method L�4ud Rotary Air Rotary ❑Auger ❑Cable Tool L]Push Point ❑ Other <br /> I <br /> Proposed Well Depth ,2- & -v Excavation in diameter E]Open Bottom &15ravel Pack/Gravel Size 6V / 2-in diameter <br /> ❑Conductor Casing ip diameter / Conductor Casing Depth ft <br /> �111ell Casing Diameter in Th �s Gquge/ASTM Sched Steel astic ❑Stainless Steel ❑Other <br /> 7 Grout Seal Depth ®r eat Cement(94 Ib bag/5-10 gal water) E]Sand Cement sack rnix/7 gal water <br /> 9 J [ entonite(20%solids) ❑Other <br /> Grout Placement Method [r]'umped ❑Free Fall [-]Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By []Driller ❑Pump Contractor Other <br /> E]Concrete Pedestal dimensions:Width ft Length ft Thick in []ChristyBox ❑Stove Pipe <br /> PUMP Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level Lmft <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 CO 10D SATION LAWS. <br /> MIN UM HO R ADVANCE NOTICE REQUIRED FOR INSPECTION;7V <br /> SSASE CALL (209) 953-7697 <br /> SIGNED — TITLE (- jt {�i-L DATE <br /> nr <br /> 0 <br /> 5 <br /> 4014 <br /> Cr <br /> \ 1 <br /> r I <br /> 9 � <br /> /J <br /> r <br /> t- <br /> E <br /> �Du . h DEPARTMENT U E qNLY <br /> Application Accepted B ` Date AreaEmployee ID# �� � <br /> Grout Inspection By Date ( ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ("1 ft <br /> COMMENTS f ( d Q <br /> r <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Service Request# <br /> o <br /> EHD 43-06 6/01/16 D✓i��lC IVQ� /_�^ /1 WELL/PUMP PERMIT <br />