Laserfiche WebLink
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 /> JOB ADDRESS I I 10 CITY/ZIP m <br /> D <br /> CROSS STREET PG w(-e S APN �ZZ_7, 00 -0/ PARCEL SIZE I AND USE APPLICATION# A <br /> OWNER NAME OA/�T(aJArJ LI tV SG�GyI PHONE � y <br /> OWNER ADDRESS D CITY/STATE/ZIP <br /> 1 _ <br /> CONTRACTOR . P ONE _ <br /> CONTRACTOR ADDRESS cp CZ 0 1 Q CITY/STATE/ZIP 1 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE &57 1 1 C-61 I I D-09 ❑ Other NUMBER EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: I I General Mineral/Coliform Bacteria(4391)Ci Dibromochloropropane(4392)n Arsenic(4393) <br /> INTENDED USE I I Domestic/Private Irrigation/Agricultural ❑ Industrial I I Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> 11 Public Water System P <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ii New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other En <br /> i I Monitoring Well(s) #of wells [I Soil Boring(s) #of borings ❑ Geotechnical_/Wf g rings <br /> I I Out-Of-Service Well ❑ Out-Of-Service Well Renewal F] Cross-Connection Repair SAIV `� 419 <br /> 11 New Pum Pum Replacement El Pump Repair 11 Raise Well CasingSDA <br /> WELL CONSTRUCTION HEAL? 0NMENT TY <br /> Drilling Method I i Mud Rotary I I Air Rotary Li Auger a Cable Tool I 1 Push Point I I Other H O'MN NT <br /> Proposed Well Depth ft Excavation in diameter I I Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched I I Steel Plastic ❑ Stainless Steel Ll Other <br /> Grout Seal Depth ft F1 Neat Cement(94 Ib bag/5-10 gal water) I l Sand Cement sack mix/7 gal water <br /> I I Bentonite(20%solids) LI Other <br /> Grout Placement Method I I Pumped 11 Free Fall ❑ Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By I 1 Driller [I Pump Contractor I I Other <br /> I1 Concrete Pedestal Ll Dimensions:Width ft Length ft Thick in LI Christy Box I I Stove Pipe <br /> PUMP Submersible 1 Turbine Ll Other HP Pump Set__&�ft Standing Water Lever ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AN HAT 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 /> WORKER %OMPENSATION LAWS. <br /> IIN 4 R V ICE REQUIRED FOR I SPECTIONS -PLEASE CALL(209) 953 97 <br /> SIGNED W&XTITLE DATE <br /> L b <br /> nil r <br /> I +H� <br /> 1 1 14 <br /> 41 1 1 V�fr T <br /> N <br /> � � t <br /> D.E ATMENT U E ONLY <br /> Application Accepted By ate ` Area /"`r"_ Z Employee ID# <br /> Grout Inspection By (� Date Air f 0 SPECIAL Well Permit <br /> Pump Inspection By Date 0 WAIVER Received <br /> Soil Boring Inspectio By '\ Date ��0 Constructed Well Depth ft <br /> COMMENTS AY� <br /> PE Sc Received < heckAmount Permitl <br /> C d Info B emitted Date Service Re uest# Invoice# Well ID# <br /> Z, Z <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />