Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT * A CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS I"t I CITYZP A(D 1�1, Gal qs�320 <br /> CROSSSTREET lI*1�,yn' Q APN ' O PARCEL SIZE LAND USE <br /> A�PPPPPLLICAATTION0 <br /> OWNER NAME V'`�v r L PHONE,'�1^� I 5J'-I✓ -01`� re <br /> OWNER ADDRESS UM//� Z 1•l CITY/STATHLP 4J�+"`IDI 1,Ca 653 2-0 <br /> CONTRACTOR �1 I I I c PHONE 2P q <br /> 572/^,I r/- G ' <br /> CONTRACTOR ADDRESS CITY/STATE21P 1 i y�/�i O G J• , C`�, 1 J�✓-7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEMP <br /> LICENSE c-57 :J C-61 0 D-09 0 Othef NUMBER 22- EXPIRATION DATE O I'3O <br /> DOMESTIC WELL SAMPUNG:0 General MineraVColiform Bacteria(4391)C Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE 0 DomesticJPrivateIrrigation/Agricul ural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterizatlon <br /> D Public Water System <br /> If different born Owner. Water System Name Cwrtad Name w Phone Number <br /> Type OF WORKew Well Replacement Well ❑Well Akeration/Modlficalion 0 Other <br /> t7 Monitoring W (s NOf Wells D Soil Boring(s) ad s 0 Geotechnical sdDwkge <br /> D Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> D New Pump 0 Pump Replacement D Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud R ❑Air Rotary ❑Auger 0 Cable Tool D Push Point ❑ Other <br /> Proposed Well Depthfl Excavation tI in diameter 0 Open Bottom Gravel Pack/Gravel Size_in diameter <br /> D Conductor Casing in diameter / Conductor Casing Depth fl <br /> Well Casing Diameter. in Thickness/Gauge/ASTM Sched tl'r kzteel `❑/Plastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth R Neat Cement(94 lb bsgr5-f 0 gal water) ql Sand cement �� 3 sack mixfl gal water <br /> 0 Bentonde(20%solids) C Other '\ <br /> Grout Placement Method Pumped 0 Free Fall D Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller ❑Pump Contractor 0 Other <br /> 0 Concrete Pedestal ODlmsnsions:Width R Length It Thick in 0 Christy Box 0 Stove Pipe <br /> PUMP 0 Submersible Turbine 0 Other HP Pump Set fl Standing Water Level R <br /> 1 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 /> MINIMUM 48 HOUR VANCE NOTICE REQUIRED F R INSPECTIONSInt-'Pµ�Lp�1E�ASE CALL(209 953-7697 <br /> SIGNED TRLE� II I 1/W'�1 V1 \ DATE �� <br /> All <br /> r <br /> RFc MFNr <br /> willAPR <br /> SAJog <br /> N 5 20?j <br /> EA�TH0�MFICV7�NTY <br /> R Tj�FNT <br /> DEPARTMENT/I ;] ONLY <br /> Application Accepted By L� Date 'T s?� Area /J Employee ID# <br /> Grout Inspecfi U SPECIAL Well Permit <br /> Pump Inspection By Date U WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth <br /> COMMENTS e..ir t;,`,_ irrr 'La 1 byl 6t, nleP rn,, y✓ (� i i,'•LJ� '�_ <br /> l <br /> — 1.' VI Y�nl inrl':l h / '� `D lYlf�tiL.h <br /> PE SC <br /> li! <br /> Received CheckV Amount Date Permit/ Invoice# Well I <br /> Codes Info Cash Remitted Se I e R seat 0 <br /> EHD 43-06 Willit �^�-740S-,53 <br /> r frS-,53 WELL(PUMP PERMIT <br />