Laserfiche WebLink
a+ <br /> 4 ' <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP //— f',� no �J�/ m <br /> r'TT m <br /> CROSS STREETi/lr�1y APN t O PARCEL SIZE LAND USE A�PJPLICATIO/N�# <br /> OWNER NAME / PHONE <br /> OWNER ADDRESS ( <br /> L 2 L(._J �( \i/ 7 P ?'1 (Q�! CITY/STATE/ZIP � CZ Cp± �� 7 <br /> CONTRACTOR 1'1/\ !I PHONE <br /> CONTRACTOR ADDRESS ` ( �t �� ��"� CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE �CC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER �� EXPIRATION DATE 3 <br /> BILLING PARTY: -1 OWNER IJ CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑ General Mineral/Coliform Bacteria(4391)Il Dibromochloropropane(4392)17 Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ ItacoMonitoring Well(s) #of wells ❑ Soil Boring #of borings s) ❑ Geotechnical `�— <br /> A <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair JUN c� <br /> ❑ New Pum Pum Replacement ❑ Pum Repair ❑ Raise Well CasingJV <br /> WELL CONSTRUCTION jo, <br /> Drilling Method El Mud Rotary ❑ Air Rotary El Auger ❑ Cable Tool ❑ Push Point ❑ Other AB E�� QV�H <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size 'FN di meter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft FNT <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ Other HP__?_ Pump Set ft Standing Water Level_; ST- 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 /> MINIMU UR AD�V�AN ICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7`6`97 <br /> SIGNED /G TITLE DATE <br /> V <br /> a <br /> V <br /> r <br /> DE) AA MENT�J'4E"'O LY i— <br /> Date I Area Employee <br /> Application Accepted By ID# <br /> Grout Inspection By Date C I SPECIAL Well Permit <br /> Pump Inspection By Date 1.1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS �, <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Re uest# <br /> EHD 43-06 6/11/2D19r��/ 77 / r WELL/PUMP PERMIT <br />