Laserfiche WebLink
WELLiPUMP PERMIT <br /> t \� SAN JOAcium COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HA2ELTON AVENUE-STOCKTON CA 95205-(209)488-3420 <br /> Ir1J�(\lJt�• NON-REFUND CALL 209 953-7697 FOR INSPECTIONC., EXPIRES 1 -A FROM RATE ISSUED <br /> JOB ADDRESS /e eY CI ✓ <br /> D <br /> CROSS STREET n N SA�O PARCEL SIZE AND USS APfL�ATION A o <br /> IfThfC ,IY^ IL a <br /> '.OWNER NAME / �MONE ' u <br /> OWNER ADDRESS G J CITY/STAT 1 l^ n7 <br /> jCONTRACTOR 114 Q r PH p� (Jt ^ A <br /> CONTRACTOR ADDRESS U 4 CITY/ <br /> 'nSTATE/Z N wll <br /> SUBCONTRACTOR ,Y PHO( <br /> SUBCONTRACTOR ADDRESS (A CITY/STATE/ZIP <br /> 1 <br /> LICENSE C-57 C-61 D-09 Other NUMB EXPIRATION DAU1,31 IZO <br /> DOMESTIC WELL S LING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) f <br /> INTENDED USE omestic/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 /> Monitoring Well(s) #of wells Soil Bonng(sl a of bonngs Geotechnical a of benngs <br /> Out-Of-Service W Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> 1 WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point. Other <br /> Proposed Well Depth ft Excavation iniQameter Open ottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / ConductcrTasing Depth ft <br /> Well Casing Diameter_in Thidmess/Gauge/ASTM Schad eel Plastic Stainless Steel Other d <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal w Sand Cement sack m/x17 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 Langt ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP_j Pump Set it Standing Water Level ft wJ <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN V` <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS LfV <br /> CURRENT AND ACTVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPE ON LAWS. l v <br /> MINIMU HOU ADVANCE NOTICE REQUIRED Het INSPECTIONS-PLEASE CALL(209) 3-7697 C <br /> SIGNED TITLE V 1�/` 1 J l VAI l/ DATE <br /> i <br /> r <br /> Off <br /> t <br /> P T M E N T U E ONLY <br /> Application Accepted By' _ Cate Area � '" Employee ID# <br />! Grout Inspection By Date � �, � PECIAL Well Permit <br /> Pump Inspection By �p�FA ArY1 r Date WAIVER Received <br /> Soil Boring Inspection By _ Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Permit/ <br /> ods Info Cash Flemitted Date ry e e uest# Invoice# Well ID# <br /> 2 /!� <br /> ".043.06 9!01116 <br /> WELL(PUMP PERMIT <br /> r �: <br />