Laserfiche WebLink
WELL/PUMP PERMIT <br /> j3AN 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 ADDRESS ILP to ``7+ pt-0-fe T-M J V CITY/ZIP `� m <br /> �I+ �q D <br /> VV CROSS STREET_r� APN ;k T VPARCEL SIZE2(JLLAND USE APP ICATION# <br /> Cn <br /> OWNER NAME / 10 PHONE1/J�/� <br /> OWNER ADDRESS C/l CITY/STATE/ZIP lX�i�, &A-g�24 2- <br /> CONTRACTOR PHONE <br /> %-� P I L�Aa Iq <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP IV�►'�Y lV� <br /> SUBCONTRACTORI 1/`/ PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 ❑ C-61 ❑ D-09 ❑ 7 Other NUMBER W EXPIRATION DATE C `G <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) 1 1 Dibromochloropropane(4392) 1 Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation 1 .), in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conduct r Casing in diameter / Cond ctor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Il ❑ Steel Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth_ I VC) ft CI Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> IKBentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Pump Contractor ElOther <br /> ❑ Concrete Pedestal ❑Di ensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ 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 /> MINI U111F U DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-769 <br /> (21" <br /> SIGNED TITLE l J , ` ��� DATE <br /> � n <br /> Fry <br /> U/ <br /> D /V <br /> E <br /> DE, ARTMENT SE ONLY <br /> Application Accepted By Date Area Employee ID <br /> Grout Inspection By �fi.y,.�r . ��c c { t Date 3 2 Z= 11 PECIAL Well Permit <br /> Pump Inspection By Date Ll WAIVER Received (f <br /> Soil Boring Inspection By Date Constructed Well Depth 6 I O ft <br /> COMMgTS <br /> ra fOA <br /> PE SC Received Ch Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Re itted Service Re uest# <br /> .2 .ZO <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />