Laserfiche WebLink
WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE VERMIT ` ` /UALL LUy UbJ-fbUf FOR INSPECTIONS tAVIKtb "I TEAR FROM UATE ISSUED <br />JOB ADDRESS "J W -57t/0/— j; CITY/ZIP J-)? /1 C CA <br />CROSS STREET 1n.4C,4R � -1u/� APN ;1 �-O �0D PARCEL SIZE C LAND USE APPLICATION # <br />OWNER NAME 15'/9 /9 (Al'oy /Yl v yy 11.4 `4 vvt PHONE Y! O ` ?O `CSG 56 <br />OWNER ADDRESS <br />CITY/STATE/ZIP <br />CONTRACTOR ,L �/ C� A '/I% � T Ca rlz 4.,,,V// / if c, PHONE aa9-�Ssq cy-6 <br />CONTRACTOR ADDRESS 19.SD`� W /' UN/* J o 3CITY/STATE/ZIP % / `n/Q c �/j C4,,/S_7 / 6 <br />SUBCONTRACTOR <br />SUBCONTRACTOR ADDRESS <br />LICENSE XC -57 El C-61 El D-09 El Other <br />PHONE <br />CITY/STATE/ZIP <br />NUMBER`'(.% 63 6 EXPIRATION DATE S/ 3//d L IS <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) []Arsenic (4393) <br />INTENDED USE Domestic/Private ❑Irrigation/Agricultural ❑Industrial E] 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# of borings <br />❑Geotechnical <br />F-1 Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />gNew Pump ❑ Pump Replacement [-]Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method E] Mud Rotary E] 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 />F-1 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 ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />E] Concrete Pedestal Epimensions: Width ft Length It Thick in ❑Christy Box ❑Stove Pipe <br />PUMP <br />Submersible [7] ❑Other HP/�/ Pump Set1�y ft Standing Water Level S 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 />���'j"j��JIMU�M�24 H UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697�f <br />SIGNED `� �E�`V "� s w TITLE l: W G DATE 7 <br />DEPARTMENT USE ONLY <br />Application Accepted By Date <br />Grout Inspection By Date <br />Pump Inspection By Date <br />Soil Boring Inspe,1c�'on By <br />COMMENTS V4 W1 <br />Date <br />T <br />m <br />D <br />0 <br />0 <br />M <br />M <br />u) <br />ur <br />AreaV Employee iD# "6 <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />ft <br />PE SC Received Check#/ Amount Date <br />Codes Info By Cashh? Remitted <br />Permit/ Invoice # Well ID# <br />Service Request # <br />�' CY <br />, w J <br />EHD 43-06 8/01/16 WELL /PUMP PERMIT <br />