Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 9520- 2 $420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> 'JOB ADDRESS /'� CITY/ZIP I <br /> 1 ! C� 1 J�p3� m <br /> ` / D <br /> �C���CROSS STREET CCjf6 h ON APN `�1 J�d�G� PARCEL SIZE"LAND USE APPLICATION# A <br /> ► � m <br /> OWNER NAME // T�r ����f N PHONE. <br /> OWNER ADDRESS �•V yCITY/STATE/ZIP PLI1•on 60L <br /> CONTRACTOR ► y UIs1 e-1 S DM �'W —Tk - � PHONE 5� <br /> CONTRACTOR ADDRESS 119 of Ib�r S CITY/STATE/ZIP / �/1d1_.'4 4r/ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP / Q 'f <br /> LICENSE �C-57 I I C-61 I I D-09 I i Other NUMBER EXPIRATION DATE kL3q <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private I I Irrigation/Agricultural 'I Industrial ❑ Water Quality Monitoring !i Soil Sampling/Charactpj tion <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Numbe <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification ❑ Other ro <br /> #of borings ' <br /> Monitoring Well(s) j of °On g <br /> 50 <br /> Out-Of-Service Well I 1 Out-Of-Service Well Renewal ❑ Cross-Connection Repair 8,%JO <br /> New Pum Pum Replacement Pum Repair ❑ Raise Well CasingENV AQ(l/N C <br /> WELL CONSTRUCTION "ZALTH D�pARTTAL <br /> Drilling Method' Mud otary I Air Rotary Auger I I Cable Tool J Push Point I Other 'V6,T <br /> Proposed Well Depth 00 ft Excavation 1 in diameter I I Open Bottom Gravel Pack/Gravel Size in diameter <br /> I i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter, in Thickness/Gauge/ASTM Sched� Li Steel lastic I I Stainless Steel I I Other <br /> Grout Seal Depth 213(9 ft ❑ Neat Cement(94 lb bag/5-10 gal water) I I Sand Cement sack mix/7 gal water <br /> ?108entonite(20%solids) ❑ Other <br /> Grout Placement Method umped I 1 Free Fall 11 Other r1 Retardant/Accelerator(name) <br /> PEDESTAL Installed By I I Driller ump Contractor I I Other <br /> ❑ Concrete Pedestal I Dimensions:Width ft Length ft Thick in I Christy Box I Stove Pipe <br /> PUMP ❑ Submersible! Turbine I 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 /> MINIM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953--70669}7) <br /> SIGNED TITLE M '1�� DATE <br /> 1 <br /> 1 G <br /> t <br /> "ev\ � PARTMEN f 9SE PNLY <br /> Application Accepted By Date Area Employee ID#� <br /> Grout Inspection By if wt Date z-4/ 1 1 PECIAL Well Pefmlt <br /> Pump Inspection By Date 1 ' WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes I o ash Remitted Service Request# <br /> lG J e�1, <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />