Laserfiche WebLink
WELL/PUMP PERMIT <br />SAN .AOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE PERMIT <br />UALL <br />LUU FOR INSPECTIONS <br />tAF'IKtb "I YEAR FROM UATE ISSUED <br />JOB ADDRESS <br />114 q 5 (,o <br />� acf�feyl� <br />�USJ-/t)Vf <br />/.ilk/ CITY/ZIP <br />1 <br />4j� 15'_7 <br />11 0 <br />La <br />b Wd <br />�44WZ <br />�� 3 J J L� <br />3F C) <br />o <br />CROSS STREET <br />1 <br />APN <br />V PARCEL SIZE <br />LAND USE <br />APPLICATION # <br />OWNER NAME <br />nnekh <br />ltbbAv-G{ <br />(rGvrolL �7au•S <br />PHONE <br />7/0( <br />-Z7Ge <br />OWNER ADDRESS <br />j/ J <br />1'475 T'yn4j) <br />i <br />�,y 2 <br />F44,41A <br />/_5 <br />a V,� <br />CITY/STATE/ZIP <br />A,M-& <br />CONTRACTOR <br />12'1 m D#2� <br />Ul, ,(, inL� <br />PHONE <br />?Z7S-% <br />CONTRACTOR ADDRESS 10/2 60K <br />3 2 / <br />CITY/STATE/ZIP <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />LICENSE )4C-57 ❑ C-61 ❑ D-09 ❑ Other <br />CITY/STATE/ZIP <br />NUMBER /D/TD-7f EXPIRATION DATE <br />- 3/ -2ozz <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) �Dibromochloropropane (4392) ❑Arsenic (4393) <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial El Water Quality Monitoring E] Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name (;ontact Name or Phone Number <br />TYPE OF WORK New Well ❑ Replacement Well ❑Well Alteration/Modification E] Other <br />J❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings E]Geotechnical # of borings <br />❑Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />Mew PumD —IPumD Replacement F]Pumo Repair F]Raise Well Casino <br />Drilling Method MMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E] Push Point ❑ Other <br />Proposed Well Depth 5(2) ft Excavation in diameter [-]Open Bottom / gGravel Pack/Gravel Size 3� e in diameter <br />[-]Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ,- 2 I ❑Steel lastic El Stainless Steel [:1 Other <br />Grout Seal Depth / ft E] Neat Cement (94 Ib bag/5-10 gal water) and Cement A::� • 3 sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method Pumped [-]Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By E] Driller []Pump Contractor ❑ Other <br />15ttoncrete Pedestal ❑dimensions: Width 4 ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP 90 Submersible❑Turbine ❑Other HP __�7 Pump Set ft Standing Water Level T ft <br />I HEREBY CER IFY 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 24 HOUR A ICE REQUIRED FOR <br />INSPECTIONS - PLEASE CALL (209) 953-76,9/7 <br />SIGN TITLE L DATE <br />DEPARTMENT USE ONLY <br />Application Accepted By Date q/ /[1 d j <br />Grout Inspection By Date <br />Pump Inspection By r U Date <br />Soil Boring Inspection By <br />COMMENTS Sr'r .)od N <br />ASS�c I ( titci C,L,ir <br />Date <br />Area y (3 C, cmpioyee iD <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />T <br />PE <br />Codes <br />SC Received Check#/ <br />Info Cash <br />Amount at Permit/ Invoice # Well ID# <br />RemittedService11equest # <br />14 21 <br />oil <br />11 0 <br />La <br />4-70 rl <br />3F C) <br />o <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />