WP0038318 - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 22 � C. m JOB ADDRESS CITY/ZIP m l Z � D CROSS STREET APN 0 PARCEL SIZE 4 I• LAND USE APPLICATION# U yil (� PHONE � OWNER NAME J/`nJ,I/� ///�►� ( OWNER ADDRESS ^ CITY/STATE/ZIP 'W*Y�1 C,®1 "1 `2�l Q/ CONTRACTOR I 1y4� l� I� r � P ONE CONTRACTOR ADDRESS_ _�1 I c �• �— VV 7 CITY/STATE/ZIP SUBCONTRACTOR 1 Y PHONE SUBCONTRACTOR ADDRESSlip CITY/STATE/ZIP LICENSE C-57 IrC-61 F1 D-09 11Other NUMBER EXPIRATION DATE DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane(4392) r Arsenic(4393) INTENDED USE ❑ Domestic/Private Irrigation/Agricultural ❑ 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 rilp Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings LI Geotechnical #of borings 11 Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump # Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method $Mud Rotary ❑ Air Rotary ❑ Auger 11 Cable Tool LlPush Point 11Other Proposed Well Depth �,/ O ft Excavation Z2 i' in diameter I-I Open Bottom Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter A& in Thickness/Gauge/ASTM Sched ct'55S JLC LI Steel ;G Plastic 1 Stainlesteel 11Other Grout Seal Depth 5-0ft 11 Neat Cement(94 Ib bag/5-10 gal wate/) ASand Cement id sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method umped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ) Pump Contractor ❑ Other ❑ Concrete Pedestal ❑Dimensions:Width_ ft Length_ ft Thick___L—in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible Turbine (I Other HP (O 0 Pump Set Q ft Standing Water Level ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORL`ANCE 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. MINIWAI 24 H UR ADVANCE NOTICE REQUIRED FOR INSPECC S - PLEASE CALL (209) 953-76970 SIGNED � TITLE DATE J O U A E P R T M E N T U 1: L Y Application Accepted By a Date Area L1 Employee ID# W U n Grout Inspection By Date 1 Q LI SPECIAL Well Permit Pump Inspection By Date 0"��1.��"LU�`t ❑ WAIVER Received Soil Boring Insp ction By Dated Constructed Well Depth ft COMMENTS Cioc e:' C T_ o PE �I C_ �•,, 4, e.� r PE SC Received hec Amount Date Permit/ Invoice# Well ID# Codes Info BYA Remitted Service Re uest# 4I�() S,-/ 7 S 23 i� oo 431u 72 5123I VU - a EHD 43-06 8/01/16 WELL/PUMP PERMIT