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 CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS CITY/ZIP �e <br />CROSS STREET APN �� PARCEL SIZE LAND USE APPLICATION # f <br />6? PHONE <br />P O E�1 <br />OWNER NAME <br />OWNER ADDRESS ::t <br />CONTRACTOR <br />CONTRACTOR ADDRESS C <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />fn `!CITY/STATE/ZIP �=AZ4&� :j i r 14 -y✓/�/L� <br />s PHON/E1 6i l�201D <br />CITY/STATE/ZIP l / I !. ✓/ ' l �./ UJ <br />PHONE i \ A <br />TE/ZIP <br />LICENSE Y(t-57 11 C-61 ❑ D-09 ❑ Other NUMBER --TIVQ %A I L v EXPIRATION DATE <br />DOMESTIC WELL SAMPLING:' i General Mineral/Golitorm Bacteria (43U1) i Ulbromochloropropane (4JUZ) ' I Arsenic (43y3) <br />INTENDED USE Domestic/Private ❑ Irrigation/Agricultural 11 Industrial LI Water Quality Monitoring I I 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 Vpll ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump Irpump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br />Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other 11 Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller 1-1 Pump Contractor ❑ 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 />WORKE COMPENSATION LAWS. <br />MUM 24 VNC .QTICE REQUIRED FOFk IN PEC_ TI;QNS - PLEASE CALL (209 953-76 <br />SIGNED TITLE DATE <br />D E A R T M E N T USE N L Y <br />r <br />Application Accepted By Date Area Employee ID# <br />Grout Inspection By ' Date U SPECIAL Well Permit <br />Pump Inspection By (� pQ-O� �riy�� �`Date ,Z� O 3� a U WAIVER Received <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Constructed Well Depth <br />PE SC Received heck#/ Amount Date Permit/ Invoice ell ID# <br />Co es Info B Remitted Service Re uest # <br />[14'14,�15 2018 <br />I COUNTY <br />ENTAL <br />HEALTH DE ART ENT <br />ft <br />FHD 43-06 8/01/4.6 WELL /PUMP PERMIT <br />T <br />m <br />D <br />v <br />M <br />M <br />Cn <br />W <br />wig <br />