WP0039845 - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CITY/ZIP m D '^ ry IS Z9 D CROSS STREET APN�Oy� PARCEL SIZE LAND USE APPLICATION# A M OWNER NAMEErii& Izo PHON _ y Cn OWNER ADDRESS CITY/STATE/ZIP LID r CONTRACTOR PHONE rIL RID� CONTRACTOR ADDRESSOW CITY/STATE/ZIP �i �I ' C?�`�vlV SUBCONTRACTOR PHONE SUBCONTRAPv6R ADDRESS TY/STATE/ZIP LICENSE -57 ❑ C-61 ❑ D-09 ❑ Other NUMBE4d&� EXPIRATION DATE DOMESTIC WELL SA LING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) , Arsenic(4393) INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial I Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-ServicW II ❑ Out-Of-Service Well Renewal [i Cross-Connecti on Repair pAYIW ElNew Pum um Re lacement ❑ Pum Re air LlRaise Well Casin ��''11 E WELL CONSTRUCTIONEIVEp Drilling Method ❑ Mud Rotary 11 Air Rotary ❑ Auger El Cable Tool ❑ Push Point [I Other G Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Grav z —2 2nf'wTa in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft �lU,/OAQV� Well Casing Diameter in Thickness/Gauge/ASTM Sched (I Steel ❑ ❑Plastic Stainless RO UN Grout Seal Depth ft [I Neat Cement(94 lb bag/5-10 gal water) F1 Sand Cement H O!PA+ ' /7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP ubmersible❑ Turbine 11 Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKEROMPENSATION I UM 24 O TICE REQUIRED FO INSPECTIONS -PLEASE CALL (209) 90-7697 SIGNED f1vTITLE AM DATE Milli J1 DEPARTMENT U E ONLY Application Accepted By Date Area l Employee ID# Grout Inspection By �/� �/�,� Date Ll SPECIALWell Permit Pump Inspection By J_ QUOf i4lklk Date ❑ WAIVER Received Soil Boring Inspection By �' ' Date (72— Constructed Well Depth ft COMMENTS IJ PE SC Receiveda Amount Permit/ Cod s Info B ash Remitted Date Service Request# Invoice# Well ID# 22 (� WPOOMS+5 EHD 43-06 8/01/16 WELL/PUMP PERMIT