Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAiI 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 /> N o r�I/.-1N ovc�s M^1n kt c 5 3 3 m <br /> JOB ADDRESS � �� CITY/ZIP m <br /> h n � /� ` � n <br /> CROSS STREET 7 �� S P V� i e APN Z 09- LLO-LJ" PARCEL SIZE ` 14 LAN US� I f- ON# /� O)u 0 <br /> OWNER NAME S �65 (� 1 L-LC S M G e1 C_S( NE �1y`G { 1 3LI ui <br /> OWNER ADDRESS 1 V U / W _ �!Y"�� CITY/ TATE/ZIP 1' `aNk p Cl\ i v <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDR�EpS�S r, T TCITY/STATE/ZIP <br /> j <br /> SUBCONTRACTOR Y`rQS,( (0(_<'1VC R)W buA"oV\ ykc PHONE <br /> SUBCONTRACTOR ADDRESS �yX nnCITY/STATE/ZIP ESca�(�I/�+CA, 153 -0 <br /> LICENSE �C-57 El C-61 [ID-09 11 Other NUMBER <br /> T7ll 01 I EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring YSoil Sampling/Characterization _ <br /> Li Public Water Systemy/-A1 Lei! Lo I-L Y 6.6 Z Z 5 <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 1�Soil Boring(s) T7 #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 Q Air Rotary ❑ Auger I 1 Cable Tool 11 Push Point ❑ Other <br /> Proposed Well Depth 1­4 ft Excavation 6L in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter int Thickn�sy�/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel Li Other <br /> Grout Seal Depth�J ft ,ql Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> El Bentonite(20%solids) !❑] Other <br /> Grout Placement Method ❑ Pumped LI Free Fall Other 11 Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller LI Pump Contractor L1 Other <br /> ❑ Concrete Pedestal ❑Dimensions: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 /> M IMUM 48 YOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br /> SIGNED T�1�\� Lc e TITLE 1 + G `r e°C DATE {1 30 <br /> ir <br /> Q / <br /> H F N <br /> M <br /> E P R T M E N T USE ON LY <br /> Application Accepted By Date Area fN Employee ID#ALUILP <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date CI WAIVER Received <br /> Soil Boring Inspection B A Date Constructed Well Depth ft <br /> COMMENTS <br /> 7 � <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted S rvice Re uest# <br /> 4-312, 1 3I C>b <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />