Laserfiche WebLink
A_ <br /> 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 1 i <br /> CITY/LP <br /> CROSS STREET 1`f ' APN1' �� I�i��l o <br /> PARCEL SIZE LAND USE APPLICATION# p <br /> OWNER NAME PHONE G •/7� <br /> V 1 ' — 1 • / <br /> OWNER ADDRESS 1 (� CITY/STATEMP <br /> LZ tq <br /> CONTRACTOR PHONE ' <br /> CONTRACTOR ADDRESS � , CITY/STATE/ZIP Gott tj(�_ <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS C <br /> ITY/STATE/ZIP <br /> LICENSE C-57 L:C-61 !'D-09 ;.!Other NUMBER C�O ExpIRAT10N DATE I <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)L;Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE I!Domesbc/Private XrrigationlAgricultural ^Industrial ;.;Water Quality Monitoring it Soil Sampling/Characterization <br /> E Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK Zew Well U Replacement Well D Well Alteration/Modification Other <br /> [.Monitoring Well(s) #of wells 0 Soil Boring(s) a of bonngs Geotechnical A of bonngs <br /> .j Out-Of-Service Well D Out-Of-Service Well Renewal ^Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MothodxMudRota U Air Rotary U Auger Cable Tool U Push Point [; Other <br /> Proposed Well Depth 4t Excavation��in diameter ❑Open Bottom Gravel Pack/Gravel Size in diameter <br /> ._I Conductor Casing in diameter I Conductor Casing Depth If <br /> Well Casing Diameter In Thickness/Gauge/ASTM Schad , LI Steel _ Plastic ❑Stainless Steel ::Other <br /> Grout Seal Depth— ,A)+ ft 0 Neat Cement(94 Ib bagl5-10 gal waler) 0 Sand Cement sack mix/7 gal water <br /> �Bentonitq(20%solids) 17 Other <br /> Grout Placement Method &Pumped 7 Free Fall U Other U Retardant/Accelerator(name) <br /> PEDESTAL Installed By J Driller D Pump Contractor Other <br /> ':I Concrete Pedestal DDimenslons:Width ft Length 1t Thick in rl Christy Box II Stove Pipe <br /> PUMP -Submersible2 Turbine (-I Other HP Pump Set ft Standing Water Level If <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 8 H A NOTICE REQUIRED FOR INSPlE1�^{ry/T19N`Cr\ L SE CALL(209)953-7697 �) <br /> SIGNED TITLE N)Vjv 1 V� � DATE <br /> lVr <br /> ?02 <br /> 1 <br /> COUN Ty <br /> H NrgL <br /> TINE T <br /> DEPARTMENT USE ONLY <br /> G Date H d3 90,;1`0 Area Employee ID# ") <br /> Application Accepted By_ <br /> Grout Inspection By �2 ('�" <br /> 7�rC �' C i / Date ElSPECIAL Well Permit <br /> Pump Inspection By Date J WAIVER Received <br /> Soil Boring Inspection By <br /> Date Constructed Well Depth tt <br /> COMMENTS <br /> PE SC Received Check/N Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted Se is Re est# <br /> '/3E 4 � 0 <br /> sr <br /> vIFLL(PUMP PERMITENO 43-C9 e/01118 <br />