Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIV COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NCIH-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> to <br /> JOB ADDRESSZ-7 CITY/ZIP m <br /> CROSS STREET /V!' /7J,/'A�w7 APN PARCEL SIZE LAND USES AAPPP12c,LICATIOON#7 �y <br /> OWNER NAME L C� I[�!� � PHONE J� 3;7-�—/ / <br /> OWNER ADDRESS �� (/ C CITY/STATE/ZIP I /!//b/� L /` 6 <br /> /' /�nL /C///�/�' /� �,/�/ i i�'�– C�J6- �� <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS /�` )� CITY/STATE/ZIP <br /> SUBCONTRACTOR � I�I �ZL� /// PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 -61 ❑ D-09 ❑ Other NUMBER 9(1 EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private rrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water S tem <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK /)-New Well ElReplacement Well ElWell Alteration/Modification F1Other <br /> ❑ Monitoring Well(s) #of wells U Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> jof4ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRU TION <br /> Drilling Method AMud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth V ft Excavation in diameter ❑ Open Bottom NIAGravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_A in _Thickness/Gauge/ASTM Sched I-1 Steel XPlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth -50 ft 11 Neat Cement(94 Ib bag/5-10 gal water) and Cement sack mix/7 gal water <br /> L143entonite(20%solids) ❑ Other <br /> Grout Placement Method Limped ❑ Free Fall ❑ Other 1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Xpump Contractor I Other <br /> ❑ Concrete Pedestal ❑ ensions:Width=aft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ubmersible❑ Turbine ❑ Other HP Pump Set�-'5Z 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 /> MI S VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 5 -7697 <br /> SIGNED r� "'L�L�I"Ly `% /� _ TITLE /Y�J%Z%/'/� DAT <br /> 00, <br /> N <br /> kt- <br /> H1111 TH DE A <br /> ATMENT U E ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date LlPECIAL Well Permit <br /> Pump Inspection By ZAnr- Date ��rL��'�1�' ❑ WAIVER Received <br /> Soil Boring Inspgction y Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received heck#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Wfo B Remitted Service Request# <br /> Z lJ. J <br /> EHD 43-06 8401/16 WELL/PUMP PERMIT <br />