Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
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 EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ln <br /> JOB ADDRESS ��/ " L CITY/ZIP � / n1 j'/ a m <br /> CROSS STREET �l��/r APN D l r �d Z� PARCEL SIZELAND USE APPLICATION# S <br /> / LU-- y <br /> OWNER NAME ! ! PHO�4NE -J <br /> OWNER ADDRESS � ✓� D L:E CITY/STATE/ZIPVVy�l1V , -/^� (/C/ <br /> CONTRACTOR (��r.$5 // /��/ PHONE <br /> CONTRACTOR ADDRESS O &j 17f'� CITY/STATE/ZIP <br /> SUBCONTRACTOR 1�J� -,h PHONE ✓ <br /> i <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 ❑C-61 ❑D-09 ❑Other NUMBER�f 7 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring E]Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK �ew Well E]Replacement Well ❑Well Alteration/Modification El Other <br /> ❑Monitoring Well(s) #ofwells ❑SoilBoring(s) #of borings E]Geotechnical #of borings <br /> F1 Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> w Pum []Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method6etfMud Rotary [-]Air Rotary ❑Auger ❑Cable Tool [-]Push Point ❑ Other <br /> Proposed Well Depth ft Excavation A/ in diameter L]Open Bottom ravel Pack/Gravel Size in diameter <br /> [-]Conductor�7Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter C? in Thickness/Gauge/ASTM Sched�L-07' ❑Steel astic E]Stainless Steel ❑Other <br /> Grout Seal DepthSI-11 ft ❑Neat Cement(94 lb bag/5-10 gal water) 516andCement /J o sack mix/7 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method'.05Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By >briller E]Pump Contractor ❑ Other <br /> E]Concrete Pedestal dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible❑Turbine ❑Other HP C 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 /> MINI jj222Q%%Q�����-�- R ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697/� <br /> SIGNED L � .� TITLEtJ(�(Ji4.�Z�L DATE (: <br /> 1 <br /> 7 <br /> r� <br /> P U T <br /> 7t' i <br /> FA <br /> EP RTMENT USE NLY ���j� <br /> Application Accepted By Date (/ Area lqq Employee ID#ice n <br /> Grout Inspection By >� fi'� Date ❑ SPECIAL Well Permit <br /> Pump Inspection By It I�4-b ti ` � Date�h I L�A 1 U ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS ' Q f ' J <br /> +. <br /> PE SC Received hec Amount Date Permit/ Invoice# Well ID# <br /> Co es Info s Remitted Service Request# <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />