WP0039684 - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMIT SAN JOAQUINACOUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NOA-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CITY/ZIP m D CROSS STREET APN PARCEL SIZE LAND USE APPLICATION# o m m OWNER NAME PHONE cn OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR _ PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE I C-57 a C-61 n D-09 11 Other NUMBER EXPIRATION DATE DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)1.1 Arsenic(4393) INTENDED USE Domestic/Private i Irrigation/Agricultural Industrial CI Water Quality Monitoring I I Soil Sampling/Characterization Public Water System If different from Owner: Water System Name Contact Name or Phone Num TYPE OF WORK INew Well Replacement Well ❑ Well Alteration/Modification Other Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings Geotechnical ��Ai#of borings%� Out-Of-Service Well ❑ Out-Of-Service Well Renewal I i Cross-Connection Repair ~'ra 1 ?01New Pum I I Pum Replacement FI Pum Repair Raise Well Casing �AN�O IJ WELL CONSTRUCTION HEq� IRO/yMF OUN7Y Drilling Method fl Mud Rotary i I Air Rotary I Auger i Cable Tool Push Point Other rH DEp'�RNA7AL j�T Proposed Well Depth ft Excavation in diameter ❑ Open Bottom I Gravel Pack/Gravel Size in diameter Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel Plastic Stainless Steel I Other Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water Bentonite(20%solids) ❑ Other Grout Placement Method Pumped I_i Free Fall 1_I Other Retardant/Accelerator(name) PEDESTAL Installed By IJ Driller I I Pump Contractor Other P Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in i Christy Box I-1 Stove Pipe PUMP ❑ Submersiblel l Turbine ❑ 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 WORKERS COMPENSATION LAWS. MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGNED TITLE DATE DEPARTMENT USE ONLY Application Accepted By Date Area Employee ID# Grout Inspection By - _ o Date SPECIAL Well Permit Pump Inspection By Date WAIVER Receive) Soil Boring Inspection By Date Constructed Well Depth_ b ft ME TS PS uCAS '04 q l�zqy PE SC Received Check#/ Amount Permit/ Codes Info B Cash Remitted Date Service Request# Invoice# Well ID# 2" 32 EHD 43-06 8/01/16 WELL/PUMP PERMIT