WP0037900 - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMIT SAN JUAQUIN COI,'.idTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 'NON-REFUNDABLE PERMIT CALL(2091953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED /,n LP ADDRESS �` 2 1 I CITY/ZIPin CROSS STREET/(it_/Ff APN i ' J "/ /`f PARCEL SIZE 1 J• LAND USE APPLICATION# v M � � N OWNER NAME JJ Q I 6 7� ��5' / �Y' PHONE Z01, L J� cn OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR PHONE 3 ZS' /►� � I / /j —cam CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR f4'� n PHONE 7 SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE C-57 11 C-61 ❑ D-09 I I Other NUMBE9_=i�_r EXPIRATION DATE -/ DOMESTIC WELL SAMPLING: Meneral Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) i Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural I_i Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK New Well ❑ Replacement Well ❑ Well Alteration/Modification I1 Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings I 1 Geotechnical #of borings / ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal I 1 Cross-Connection Repair A4qeW Pump ❑ Pump Replacement ❑ Pump Repair Il Raise Well Casing WELL CONSTRUCTION Drilling Method*<'Mud Rotary ❑ Air Rotary 11 Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth"'O ft Excavation in diameter [1 Open Bottom <Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter In Thickness/Gauge/ASTM Sched�'tf� ❑ Steel>KPlastic ❑ Stainless Steel ❑ Other Grout Seal Dept ❑ Neat Cement(94 Ib bag/5-10 gal water) o<Sand Cement ��.`i sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method<Pumped ❑ Free Fall 11 Other 11 Retardant/Accelerator(name) PEDESTAL Installed By.•C'briller ll Pump Contrao LI Other 11 Concrete Pedestal (]Dimensions:Width ft Length ft Thick in ❑ Christy Box Stove Pipe PUMP a<Submersiblell Turbine ❑ Other HPPump 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. MINI UM 24 FWR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 � f�J i SIGNED ,6 . C� TITLE �/�C7`- DATAt' I2 TIT O O '9 A r�i Nvi Z is T v 3 i_ O IN L Application Accepted By Date - ) I Area Employee ID# Wo/� Grout Inspection By orck t(nce�$ 2"�` � I F] SPECIAL Well Permit Pump Inspection By Date 0,2 law ❑ WAIVER Received Soil Boring Inspection y Date Constr cted Well Depth ft COMMENTS 1 JW 4��A Y" . ��L�P� ��Y� ��I;P� l� 1� ,�1 �L�� nT45 -0 PE SC 0eceived Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info Cash Remitte Service Request# 3 l3 2 i• I W 00� C1 C1 430 0- lQ — 353-51 21111TIWO 00 I EHD 43-06 8/01/16 WELL/PUMP PERMIT