Laserfiche WebLink
! j <br /> WELL/PUMP PERMIT i <br /> .SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS XPIRES 1 YEAR FROM DATE ISSUED <br /> Ln <br /> fY,JOB ADDRESS ! �a J . ��/C� CITY/ZIP m <br /> /7 D <br /> CROSS STREET ' APN PARCEL SIZE } LAND USE APPLICATION# <br /> ) <br /> CA <br /> OWNER NAME `- ✓"� PHONE 2� <br /> OWNER ADDRESS o/` ✓�S CITY/STATE/ZIP C <br /> 0 FM <br /> CONTRACTOR C. PHONE <br /> CONTRACTOR ADDRESS � � L�a CITY/STATE/ZIP <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE >a C-57 ❑C-61 r-1 D-09 Ll Other NUMBER J! %( EXPIRATION DATE <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391)❑Dibromochloropropane (4392)❑Arsenic(4393) <br /> INTENDED USE ❑Domestic/Private rigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> If different from Owner: Water System Name Uontact Name or PhoneN mer <br /> TYPE OF WORK ANew Well ❑Replacement Well ❑Well Alteration/Modification El Other 70'(-'1<. Co X 4-1- <br /> [-] <br /> U` — <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings <br /> L]Out-Of-Service Well E]Out-Of-Service Well Renewal [_]Cross-Connection Repair <br /> >5New Pump ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method,*;rMud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E]Push Point ❑ Other <br /> Proposed Well Depth-0 ft Excavation i 2— in diameter E]Open Bottom "":Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter6— Thickness/Gauge/ASTM Schede' _ [:]Steel .�&lastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) and Cement sack mix17 gal water <br /> ❑Bentonite(20%solids) ❑Other <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By k4riller ❑Pump Contractor ❑ Other <br /> E]Concrete Pedestal dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP Submersible❑Turbine ❑Other HP Z— 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 /> MII/NNIUM 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)953-7697 <br /> SIGNED z.��,/ TITLEj 4ZL'-A DATE <br /> -r <br /> E IN CC UN <br /> t:AIrTh p L <br /> it <br /> Dt 6HR T fihEN T JE NL T <br /> Application Accepted By Date Area Employee ID# -!Eb <br /> Grout Inspection By 1Yt Date ❑ PECIAL Well Permit <br /> Pump Inspection By. w"�' j) Q�l���� Date t t�� �.� j ❑ WAIVER Received <br /> Soil Boring Inspejtion By Date Co tructed Well pth `7 5 ft / <br /> CO MENTS ! ✓ <br /> Y c N7 <br /> PE SC Received Amount PermiU <br /> Codes Ifo B Cash emitted Date Service Request# Invoice# Well ID# <br /> C <br /> Zb �j(Q'CY) <br /> EHD 43-06 6/01/16 WELL/PUMP PERMIT <br />