Laserfiche WebLink
JOB ADDRESS _ cAr ti)/Ap CITY/ZIP */#18A1 /G2/ <br />CROSS STREET rit gq APN 7 • 7 /be -4v PARCEL SIZE LAND USE APPLICATION # <br />‘2C7 9/ 2ffiewkii4f:Arhef PHONE 6/eq) 3M17 <br />eAk t <br />CITY/STATE/ZIP <br />PHONE <br />CONTRACTOR ADDRESS <br /> <br />CITY/STATE/ZIP <br />SUBCONTRACTOR <br /> <br />PHONE <br />SUBCONTRACTOR ADDRESS <br /> <br />CITY/STATE/ZIP <br />LICENSE C-57 I C-61 11 D-09 I I Other <br />NUMBER <br /> <br />EXPIRATION DATE <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />,tiAl Jc1/41 6 29P <br />c.1-4 <br />-„,, 44, Q. <br />""//R0A, C <br />Ott 2 <br />Ty -utik-N <br />,‘ /A/kw <br />vc.0 <br />911V'f1/4, <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />5t=42 Ccal <br />D ILRTMENT <br />Date <br />Date <br />Date <br />Date <br />WELL/PUMP PERMIT <br />EAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT <br /> CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE I I Domestic/Private I Irrigation/Agricultural I Industrial 1_1 Water Quality Monitoring ' Soil Sampling/Characterization <br />11 Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK <br />I New Well LI Replacement Well <br /> <br />LI Well Alteration/Modification II Other :SS3ICICIV 3119 # of borings [1 Monitoring Well(s) # of wells # of borings Soil Boring(s) 11 Geotechnical <br />Out-Of-Service Well <br /> 11 Out-Of-Service Well Renewal E Cross-Connection Repair <br />1 New Pump I I Pump Replacement 11 Pump Repair 0 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ,1 Mud Rotary 11 Air Rotary 11 Auger H Cable Tool Li Push Point Other <br />Proposed Well Depth ft Excavation <br /> <br />in diameter E 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 Sched 11 Steel LI Plastic ' Stainless Steel II Other <br />Grout Seal Depth ft Cl Neat Cement (94 lb bag/5-10 gal water) 0 Sand Cement sack mix/7 gal water <br />LI Bentonite (20% solids) ID Other <br />Grout Placement Method I Pumped 17 Free Fall Other 1_1 Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller 11 Pump Contractor <br /> <br />Other <br />0 Concrete Pedestal I Dimensions: Width ft Length ft Thick in • Christy Box i Stove Pipe <br />PUMP E 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 />MINIMU48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIOrIS - PLEASE CALL (209) 953-7697 <br /> <br />TITLE>i e) DAT <br />/1-i-rkar-to <br />SIGNED <br />Area Employee ID# <br />LI SPECIAL Well Permit <br />0 WAIVER Received <br />Constructed Well Depth ft <br />(1 COMMENTS \,`,1 <br /> 1/4) \..\-% <br />PE <br />Codes <br />SC <br />InfA <br />Received <br />By <br />Amount <br />Remitted Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />Cash <br />Plee4- IT W OW / 33'T i (V : Ii41 ) IA) r ltr57 1 5 <br />EHD 43-06 8/01/16 <br /> WELL /PUMP PERMIT