Laserfiche WebLink
WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 - (209) 468-3420 <br />NUN-KEFUNDABLE FERMITC <br />LALL ZU9 903-l697 FOR INSPECTIONS <br />EAPIIKES 1 YEARFROMDATE ISSUED <br />JOB ADDRESS 1 5 0C� 4 fn A� <br />r lJ (11 %A (Zt A <br />CITY/ZIP1-3 <br />` <br />C <br />CROSS STREET J ` Cr Vt� M'1 'firee PN �yJ� /D 3 7 PARCEL SIZE <br />�d <br />LAND USE APPLICATION # <br />D (� <br />OWNER NAME 1 AV 1 `� YV <br />,OWNER ADDRESS I <br />iy f?k'V1(704 0q <br />�G 1Jl.l�' ��11�'I �� b) <br />!-�` <br />CIN/STATE/ZIP <br />PHONE `— \ a <br />1—G� <br />i d <br />-e�--, <br />CONTRACTOR @`i <br />``'f NO, <br />PHONE ani 1 <br />CONTRACTOR ADDRESS C0 t , <br />CITY/STATE/ZIP <br />I r I a L�— <br />SUBCONTRACTOR <br />PHONE <br />SUBCONTRACTOR ADDRESS <br />ILICENSE >(C-57 ❑ C-61 ❑ D-09 ❑ Other. <br />CITY/STATE/ZIP <br />NUMBER y.? `1 a �� EXPIRATION DATE i _3 / — l <br />DOMESTIC WELL SAMPLING: ❑General Mineral/Coliform Bacteria (4391) ❑Dibromochloropropane (4392) [-]Arsenic (4393) <br />INTENDED USE ❑ Dom estic/Private-IgIrrigation/Agricultural ❑Industrial ❑ Water Quality Monitoring El Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water 6ystem Name Contact Name or Phone Number <br />TYPE OF WORK ❑ New Well Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical # of borings <br />❑Out -Of -Service Well ❑Out -Of -Service Well Renewal ❑Cross -Connection Repair <br />New NUmD I II'Um <br />fraise vveii <br />WELL CONSTRUCTION <br />Drilling Method `Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool E] Push Point ❑ Other <br />Proposed Well Depth a -O0 ft Excavation /r, in diameter ❑Open Bottom ,Gravel Pack/Gravel Siz in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter 121. in Thickn=aASTM Sched 5 ��. a� ❑Steel JkPlastic ❑Stainless Steel El Other <br />i <br />Grout Seal Depth iq �ftnt (94 lb bag/5-10 gal water) `nand Cement 1C. sack mix/7 gal water <br />❑ Bentonite (20% solids) ❑ Other <br />Grout Placement Method Wumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />❑Concrete Pedestal dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe <br />PUMP Submersible❑Turbine ❑Other HP Pump Set ft Standing Water Level •b 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 AN ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS C PENSATION LAWS. <br />MI MU 24 R DVANCE NOTICE REQUIRED FOR INSPECTI/QJMS -PLEASE CALL (209) 953-7697 �j <br />SIGNED TITLE �to fly' /'�-rs DATE 6 � � � � / <br />DEPARTMENT USE ONL1 <br />Application Accepted By Date CD <br />Grout Inspection By Date .13 <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS SE -,F- ka-A C44 <br />W cLu A_"J 4 <br />e F Ei-r 0 <br />Date <br />Date <br />�1l�Rsr�'JI! U■ NEEMEII 1 <br />s+ 7` <br />Employee <br />■ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />o��✓F_S � .vS7Y� <br />PE SC Received he Amount Date Permit/ Invoice # Well ID# <br />Codes Info B*, Cash Remitted Service Request # <br />4�� i ! FN x`10 �,. (_ �.� (v -71 U J % <br />ft <br />EHD 43-06 8101/16 C e)(Ij-rh�� I ����( �' �ro M :� U�� 5"177 <br />"17% 312- 1 �r gq�MIT <br />T <br />%1 <br />