Laserfiche WebLink
SAN JOAQUIOUNTY ENVIRONMENTAL HEALTH DEPAR WELUPUMP PERMIT <br />1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS <br />Zg2 EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS o N N Q6 O <br />CITY/Zip � ` <br />CROSS STREET APN �� �� <br />PARCEL SIZEIJ1ND USE APPLICATION # <br />OWNER NAME <br />OWNER ADDRESS Y 0 00X( G'ngL� jt j V 11 PHONE U►1 7 U <br />MA 715IIIA DY��IIN(J) 1NG CITYISTATEJZAIIN_ AN GA Q9Z� <br />CONTRACTOR Hry��,y�,yC�_7/ Pa=R7 <br />22'CONTRACTOR ADDRESS Vl!t1 r4\ .MCt7Y/STATE/LP <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS Cm/STATE/LP <br />LICENSE IC -57 ❑ C-61 u D-09 G Other NUMaER\jjj&U1'Z- —". <br />EXPIRATION DATE <br />JUA1rt, I IL; WELL SAMPLING: 0 Gener 1 MineraUCOliforrn Bacteria (4391) C1 Dibromochloropropane (4392) ❑ Arsenic (4393) <br />NTENDED USE ❑ Domestic/Private Irrigation/Agricultural ❑Industrial �� Water QualRy Monitoring ❑Soil SamplinglCharacterization <br />❑ Public Water System <br />It diflareM hom Owner- Water System Name Contact Name or Phone Number <br />YPE Oc WORK 1,,NewWell ❑ Replacement Wall O Well Alteration/Modification ❑ Other <br />C Monitoring Well(s) S Of wells ❑ Soil Boring(s) • 0 borings D Geotechnical <br />^ OW -OT -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />• or bonrps <br />Drilling Method 3CMud Rotary ❑ Air Rotary 11 Auger ❑ Cable Tool 11 Push Point El Other <br />Proposed Well ' \_ <br />R ^A', <br />Depth Excavation in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing�pth' RWell Casing Diameter in Thickness/Gauge/ASTM Sched t ael C Plastic ❑ Stai I s Steel ❑ Other <br />Grout Seal Depth- R ❑ Neat Cement (9416 bagr5-10 gal watG Sand Cement sack m1x/7 gal water <br />C Bantond (20% solids) ❑ Other <br />Grout Placement Method Pumped ❑ Free Fall D Other ❑ Retardant / Accelerator (name) <br />PED STAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑ Concrete Pedestal ❑Dimenslons: Width _ R Length R Thick in G Christy Box Stove Pipe <br />PUMP 0 Submersible❑ Turbine ❑ Other HP Pump Set R Standing Water Level R <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. 1 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 />y <br />m <br />D <br />g <br />a <br />DEPARTMENT BE ONLY <br />Application Accepted By l�'�L L Date (? �r �7 Area / �' Employee ID# a 5 <br />Grout Inspection By Dale ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />EHD 43-06 8101/16 <br />WELL /PUMP PERMIT <br />