Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
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 P-,C, YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1 S At�IC S CJ n e- �f' CITY/7JP P' ,LCl <br /> CROSS STREET �-T(�� C .rJCC'I ,A1PN `c()'c� `�J3t•�4^G�J' ►�iPARCEL SIZE LAND USE APPLICATION�# r� o <br /> OWNER NAME y1( ' I 't'Irl V1oyY �lifl FY J-S 1t. J PHONE LI�C./� ,/-?oO'51.1c) 'I u�+ <br /> OWNER ADDRESS �`•.V t 1;CI A �Ci 1! �y� � CITYISTATEZP �>T Ci C.K `�•1 9 r 9` <br /> CONTRACTOR V Ifs� 1)r, `I \n L, PHONE a/c^1[�3 q-�[i,�•7q <br /> CONTRACTOR ADDRESS pc, o L Y I CITY/STATEZP I�r l v\ 9 S�J�2 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS �CJITYIIIS`TA`4TEZP <br /> LICENSE C-57 C-61 ❑D-09 D Other NUMBER`�CI I Jul EXPIRATION DATE =31 C <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)r Arsenic(4393) <br /> INTENDED USE omestic/Privale Irrigation/Agricultural Industrial ! 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 New Well !..'Replacement Well D Well Alteration/Modification ❑Other <br /> r:Monitoring Well(s) #of wells ❑Sod Boring(s) a of bonngs Geotechnical a of borings <br /> !-.Out-Of-Service Well D Out-Of-Service Well Renewal U Cross-Connection Repair <br /> New Pum I Pump Replacement D Pump Repair a Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method'k Mud Rotary, ; Air Rotary ''-Auger C Cable Tool 1 Push Point Other <br /> i <br /> Proposed Well Depth -275 ft Excavation�'3 in diameter _ Open Bottom ')�Gravel Pad(/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter(L In Thickness/Gauge/ASTM Schad C11 LC ❑Steel )X Plastic Stainless Steel i-i Other <br /> Grout Seal Depth )CLI 11 -:Neat Cement(94 Ib bag15-10 gal water) Sand Cement I C 5 sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method X Pumped f:Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL I stalled By �f,,Driller '..Pump Contractor Other <br /> Concrete Pedestal DDlmensions:Width � ft Length .i it Thick in G Christy Box !-:Stove Pipe <br /> PUMP }4 Submersible)Turbine D Other HP 7 Pump Set=it Standing Water Level <br /> I HEREBY CERTIFY THAT 1 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMU : -'-'HOUR,ADVANCE NOTICE REQUIRED FOR1 INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED �•( //L`/"r�L'�'\ TITLEAe til DATE <br /> G� <br /> 1 <br /> T <br /> J <br /> f 1 <br /> v 3 <br /> 1 <br /> L l <br /> I <br /> _7 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Dale r SPECIAL Well Permit <br /> Pump Inspection By Date .! WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice III WellID# <br /> Codes Into B Cash Remitted Service Re uest# <br /> EHL 43-06 revised 4/14/16 WELL/PUMP PERMIT <br />