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 P �'? 'C l�- R 1'*l' _ CITY/ZIP Al '4 <br /> m <br /> D <br /> CROSS STREET �J N 5 Irl 14 ��! , APN 1Xk2S PARCEL SIZE LAND USE APPLICATION## <br /> m(n <br /> OWNER NAME m a __ __ PHONE <br /> OWNER ADDRESS __7C�e1 1 2_ CITY/STATE/ZIP <br /> CONTRACTOR -j�-'j/��"j?/tom L�t� /�1(A/}- PHONED3 GU'-7 <br /> CONTRACTOR ADDRESS `4 STti 1' CITY/STATE/ZIP LTO`/ <br /> SUBCONTRACTOR /�L f i� PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE i t-57 C-61 i D-09 Other NUMBER r 1 , EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)[1 Dibromochloropropane (4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial ❑ Water Quality Monitoring Xsoil 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 /> I; Monitoring Well(s)_ _ <br /> ._ _ __ #of wells l_ <br /> Soil Boring(s) #of borings Geotechnical a of borings <br /> I I Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> I New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary /Auger Cable Tool Push Point Other <br /> Proposed Well Depth 16 ft Excavation _ � in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel L1 Plastic Stainless Steel Other <br /> Grout Seal Depth .It eat Cement(94 Ib bag/5-10 gal water) fl Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller U Pump Contractor Other <br /> Concrete Pedestal 'Dimensions:Width It Length If Thick in Christy Box I Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT 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 /> MINIMUM 48 HOUR ADVANCE NOTICE R QUIRED FOR INSPECTIONS - PLEASE CALL(209) 95 -7697 <br /> SIGNED -TITLE ILDATE <br /> y <br /> a <br /> _ NTY <br /> EN V I O N ME 11T L <br /> H Al H Da 5A• ENT <br /> ���✓' ���"1)EPARTMENT US7E�O LY <br /> Application Accepted By / I Date Area %' LL1 Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date n / WAIVER Received <br /> Soil Boring Inspection By kY' Date Q l Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Request# <br /> 2 S S" �o• I°i 2 <br /> END 43-06 6/01/16 WELL/PUMP PERMIT <br />