Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE ERMITWWW S OV.OI /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> 5a s <br /> Job ADDRESS CITU/ZIP m <br /> D <br /> CROSS STREE APN OFZ)3009 PARCEL SIZE 1 LAND USE APPLICATION# <br /> OWNER NAME 1F P]H�� <br /> >ONEq� r/� y <br /> OWNER ADDRESS �y CITY/STATE/ZJP( J(/ l y J �l./����Li <br /> CONTRACTOR 11w, PHONE <br /> CONTRACTOR ADDRESS C1 <br /> ` CITY/STATE/ZIP <br /> SUBCONTRACTORICONSULTANT \/h PHONE <br /> SUBCONTRAC OR/CONSULTANT ADDRESS CI / ATE/ZIP _ <br /> LICENSE 57 C-61 i D-09 Other NUMBER EXPIRATION DATE <br /> BILLING RTY: OWNER .CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELLS MPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> ublic 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 /> MonitoringWell(s) #of wells SoilBoring(s) #ofbodngs Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum p-ump Replacement I 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 ft Excavation in diameter Open Bottom 1 Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94/b bag/5-f0 gal water) Sand Cement sack mixf7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped i Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine i Other. HP Pump Set ft Standing Water Level It <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 COM ENSATION LAWS. <br /> MIN U CE NOTICE REQUIRED FOR NS'P�E/CJTTII^ONS-PLEASE CALL(209)953-7097 <br /> SIGNED �`� TITLE ��'%�OL�' DATE ' < <br /> NJ <br /> 110 <br /> q <br /> O <br /> 9EPARTMENTSbE ONLY <br /> Application Accepted By AL Date Date �Q ZvZO Area Employee ID# DA <br /> Grout Inspection By n Dale I SPECIAL Well Permit <br /> t— <br /> Pump Inspection By Fy`W�sLO gj1P , 0.1 1t Date LC i WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check Amount PermiU <br /> Codes Info B as Remitted Date ice Re ue Invoice# Well ID# <br /> EHD 43-06 6111r1019 WELL/PUMP PERMIT <br />