WP0037345 - Laserfiche WebLink

Home Browse Search

� rl WELL/PUMP PERMIT v SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 NUN-KEFUNDAB JOB ADDRESS � CROSS STREET OWNER NAME OWNER ADDRESS CONTRACTOR CONTRACTOR ADDRESS SUBCONTRACTOR ERMIT CALL 209 953-7gR7 FOR INSPECTIONS E PIRES 1 YEAR FRONT, DATE ISSUED T J (n CITY/ZIP PN VO I 1 �JV PARCEL SIZE w ` , LAND USE APPLICATION # /1 ONEr/I 77 / CITY/STATE/ZIP /y SHONE�CITY/STATE/ZIP SUBCONTRAT R ADDRESS / LICENSE NC -57 ❑ C-61 ❑ D-09 ❑ Other PHONE CI */ TATE/ZIP NUMBER. flEXPIRATION DATE - NTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring El Soil Sampling/Characterization Public Water System If different from Owner: Water System Name Uontact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well []Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings # of borings ❑Geotechnical E] Out -Of -Service PVPII ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair ❑ New Pump M Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION fj Drilling Method E] Mud Rotary ❑Air Rotary ❑Auger [:]CableTool E] Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic E] Stainless Steel ❑Other Grout Seal Depth ft ❑ Neat Cement (94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite (20% solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By ❑Driller E] Pump Contractor ❑ Other Concrete Pedestal dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP it Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND'THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. E REQUIRED SIGNED DEPARTMENT USE ONLY Application Accepted By /� Date 2' Grout Inspection By Date Pump Inspection By'AA Date Soil Boring Inspection By Date COMMENTS PLEASE CALL (209/)x95-769 DATE "� /91W T 1 m D v v rn rn U) y NAil Area I Lr f Employee ID#Ahmed . ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft PE Codes SC Info Received Chec ash Amount DatePermit/ Invoice # Well ID# Remitted Service Request # C s EHD 43-06 8/01/16 WELL /PUMP PERMIT