Laserfiche WebLink
WELL/PUMP PERMIT I L <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 ADDRESSI V �- I�L� ""op A IC� a CITY/ZIP /scam -p o i / _A- 42suo <br />CROSS STREET _ 13{.1 t /�fP�N V ��� �C7PARCEL SIZE LAND USE APPLICATION # <br />OWNER NAME 1V iti "' I ' a oy Lc cm fr,� PHOLNE + • 2 <br />OWNER ADDRESS 10 0 0 CITY/STATE/ZIP �/•ftd {Cn <br />CONTRACTOR A&Sdht Dr1"'{TPHONE ✓-I } (7p <br />CONTRACTOR ADDRESS -1 ► q A ibefs Rd __ CITY/STATE/ZIP �O ( / ✓/ `��� <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE ;KC -57 l C-61 I' D-09 I Other <br />CII�TYI¢STATE/ZIP_ <br />Ip&%7- <br />BER Z <br />PHONE <br />EXPIRATION DATE q-30 <br />DOMESTIC WELL SAMPLING: General Mineral/ColifoNB'ac 1V1) Fl 1 Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE ❑ Domestic/Private Irrigation/Agricultu�f� 1 ustrial ❑ Water Quality Monitoring li Soil Sampling/Characterization <br />11 Public Water System <br />If different from Owner: Water Svslem Name Contact Name or Phone Number <br />TYPE OF WORK New Well ❑ Replacement Well ❑ Well Alteration/Modification I I Other <br />Li Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings 1 Geotechnical # of borings <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal 1 Cross -Connection Repair <br />❑ New Pump ❑ Pump Replacement ❑ Pump Repair I 1 Raise vveii uasin <br />WELL CONSTRUCTION <br />Drilling Method)<Mud Rotary ❑ Air Rotary 1.1 Auger [] Cable Tool Li Push Point El Other <br />Proposed Well Depth 400) ft Excavation � in diameter 1 1 Open Bottom XGravel Pack/Gravel Size in diameter <br />F1 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter tZin Thickness/Gauge/ASTM Sched 201D U Steel lastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth 50 ft ❑ Neat Cement (94 Ib bag/5-10 gal water) Sand Cement L40 • ,3 sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other n Retardant / Accelerator (name) <br />PEDESTAL• By J Driller n Pump Contractor [I Other <br />PedestalF.] Concrete . •th ft Length ft Thick in 11 Christy Box I Stove Pipe <br />Pump [I SubrnersibbineOther HIP Pump Set ft Standing Water Level -ft <br />APPLICATIONI HEREBY CERTIFY THAT I HAVE PREPARED THIS •' DONE IN ACCORDANCE <br />WORKERSJOAQUIN 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 />• • <br />SIGNEDMl!!!��HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />r. DATEI 1 <br />■■■■■■■■■■■■■■■■■■■■■� ■■■■■■■■■■■■■■■■■■■■. <br />.■■■■■.■■■■.■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■.■ <br />■■■■■■■■■■■■■■■■■■■■�■■■ ■■■■■■�l��fY■■■It■■ <br />■■■■■■■■■■■■■■■■■■■■ ■■■ ■.■■■■1�!�'■■It■■ <br />■■■■■■.■■■■■■■■■■■■■■ ■■ ■■■■■■■�IiYI�Kt�■■■t�■■ <br />■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■MMEM■W■■ <br />Application Accepted By &&v Date Area Employee ID# W&d* <br />Grout Inspection By IrbDate I SPECIAL Well Permit <br />Pump Inspection By rhRmm U I Date — I WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS J <br />T <br />D <br />0 <br />0 <br />M <br />M <br />En <br />Y <br />PE Sc Received heck#/ Amount <br />Codes 1 fo By Remitted ate <br />Permit/ <br />Invoice # Well ID# <br />Service Re uest # <br />P 66 -N -7 <br />ve- <br />EHD 43-06 6/01/16 WELL /PUMP PERMIT <br />