Laserfiche WebLink
WELL/PUMPPERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTONCA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 2- Ol G - W �3 JP <br /> JOB ADDRESS Clryl[Ip m <br /> 2 -D 0-nD `1 <br /> CROSS STREET APN PARCEL SIZE 11�LAND USE',//AP1r�'PLICATION#OWNER NAMEIng" <br /> }(/� ' `' PHONE (/V�OWNER ADDREl , CITY/STATE/ZIP CAN b el�f �{ L.(1�/ <br /> CONTRACTOR S PHIlOff{{ffNUUEEn'�Z L ' 1 j12� ) <br /> CONTRACTOR ADDRESS 1 .� CITY/STATE/ZIP Old}1 V i JV) ���/� <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYISSyTATEIZ'IIP� <br /> LICENSE C-57 D C-61' ❑D-09 ❑Other NUMBER L. _� EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane,(4392)D Arsenic(4393) <br /> INTENDED USEDomesticlPrivate ❑Irrigation/Agricultural �D Industrial D 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 qt/New Well D Replacement Well D Well Alteration/Modification ' D Other <br /> ,❑,Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> D Out-Of-Service Well D Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> D New Pump ❑Pump Replacement ❑Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)(Mud Rota D Air Rotary 0 Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth Pro <br /> p p �. it Excavation in diameter 11 Open Bottom. Gravel Pack/Gravel Sizelt in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter(Lin in Thickness/Gauge/ASTM Sched 2nO ❑Steel Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth JQU ' ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) D Other <br /> Grout Placement Method Ypumped ❑Free Fall D Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller .Pump Contractor D Other <br /> ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in 0 Christy Box D Stove Pipe <br /> PUMP D Submersible[]Turbine ❑Other HP Pump Set_ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND TFfiAT 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 /> MIN/ �n <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209))953-769p7 <br /> SIGNED J/l(_ y�r.GlL.a.".- ' TITLE �i�r•l�.Q Y' DATE <br /> t to q <br /> i <br /> I 1 71 <br /> Ic <br /> n <br /> T <br /> D <br /> A <br /> 4 a; eve Cu <br /> DE,PARTMENTseUSE 0 LY 11HDEP'4RTML <br /> Application Accepted By - r Date !,� Area — Employee ID# Ct <br /> Grout Inspection By Date D SPECIAL Well Permit <br /> Pump Inspection By Date Ll WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Rjequest# <br /> © 41 1,1_-7o 00 quio <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />