Laserfiche WebLink
I WELL/PUMP PERMIT <br /> SAN 50AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON..-REFUN BLE PERMIT L I CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROMDATEDATE ISSUED <br /> u Lu.JOB ADD ESS Ln <br /> ���j D%Ie/,i �D�C CITY/ZIP W00,L IGS / /J�'�U m <br /> (.90 D <br /> CROSS STREET N, APN���'�4V �� PARCEL SIZE 01-S LAND USE APPLICATION# <br /> A /� m <br /> OWNER NAME Al♦ f-r�` O �/ P ONE y <br /> OWNER ADDRESS y/` � CITY/STATE/ZIP <br /> CONTRACTOR )ecrc►COn 1 ell 0• 4ccui, /r PHONE ZD I -2911 - 7223 <br /> CONTRACTOR ADDRESS q O2- yiiJks5 ri,-1 ivky CITY/STATEIZIP L0�I AA1j,, L go <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CI/TY/STATE/ZIP J <br /> LICENSE -57 11 C-61 I I D-09 I Other NUMBER 6 EXPIRATION DATE 5-3 1 -2 02./ <br /> DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392) 1 Arsenic(4393) <br /> INTENDED USE f I Domestic/Private LI Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring Nsoil Sampling/Characterization <br /> I I 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 n Other <br /> ❑ Monitoring Well(s) #of wells XSoil Boring(s)_2— #of borings LI Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal I I Cross-Connection Repair <br /> ❑ New Pump Pump Replacement ❑ Pump Repair I I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method F1 Mud Rotary Li Air Rotary XAuger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth S ft Excavation in diameter I 1 Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> I I Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched I l Steel Il Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft )<Neat Cement(94 lb bag15-10 gal water) I I Sand Cement sack mix/7 gal water <br /> I I Bentonite(20%solids) 1.1 Other <br /> Grout Placement Method ❑ Pumped X Free Fall I I Other I I Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller I 1 Pump Contractor ❑ Other <br /> i i Concrete Pedestal ❑Dimensions:Width ft Length ft Thick in n Christy Box 11 Stove Pipe <br /> PUMP i I Submersible Turbine I I 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 /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FOR INS//P''/E��CTII'ON/S - PLEASE CALL(209/) 953-7697 <br /> SIGNED IPOVV 4 TITLE �T_'1" GE0t0h_S1— DATE 6 -2 - <br /> / ell <br /> ViG <br /> IN <br /> UN <br /> LN rL <br /> IV <br /> DE A TMENT U E O LY <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date ❑ PECI L Well Permit <br /> Pump Inspection By _ Date ❑ WAIVER Received <br /> Soil Boring Inspection By _ Date - Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received <5hec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted Service Re uest# <br /> b-25•I°� '1S <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />