Laserfiche WebLink
i. <br />III t <br />WELL/PUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />1668 Easr HAZELTON AVENUE - Siocl<roN CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT hArWW.S� OV.OI' /ehd <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 7_ LC5 E C"VA:nP� <br />— <br />CROSS STREET CITY/�PAPN PARCEL SIZE0 a 0rr_�—LAND USE APPLICATION # <br />OWNER NAME J <br />PHONE <br />OWNER ADDRESS 12"I E f„�r hKyl cl . �� �.��� <br />1 CITY/$TATEI71P <br />CONTRACTOR ADDRESS L <br />CIN/STATE/ZIP <br />PHONE Z_til% -VI �-')I <br />PHONE_ ]\ <br />SUBCONTRACTOR/CONSULTANT ADDRESS �--'Y- <br />CITYISTATE/LP I <br />LICENSE XC -57 C -6i4-09 Other 4 /// <br />NUMBER EXPIRATION DATE <br />BILLING PARTY: OWNER CONTRACTOR <br />SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: _ General Mineral/Coliform Bacteria (4391) __ Dibromochloropropane (4392) _ Arsenic (4393) <br />INTENDED USE _ DomestldPriVate I <br />Public Water System mgahon/Agricultural - Industrial - Water Quality Monitoring _ Soil Sampling/Charactenzaticn <br />If dilfarent from Owner: Water System Name <br />Contact Name or Phone Numhar <br />----------------- <br />INew vvell Replacement Well Well Alteration/Modificalion <br />Other <br />Monitoring Well(s) # of wells Soil Bonng(s) x of borings <br />Oul-Of-Service WellGeotechnical x of borings <br />Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pump Pump Replacement - Pump Repair <br />WELL CONSTRurn -Raise Well Casinn <br />Drilling Method Mud Rotary Air Rotary _ Auger Cable ToolPush Point Other <br />Proposed Well Depth k Excavation <br />n diameter Open Bottom Gravel Pack/Gravel Size <br />Conductor Casing in diameter / Conductor Casing Depth k in diameter <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad <br />Grout Seal Depthk . Steel Plastic - Stainless Steel Other <br />Neal Cement (94 lb bag/5-10 gal water) Sand Cement <br />Bentonite (20% solids) _. Other Sack rn"wR gal water <br />Grout Placement Method - Pumped Free Fall Other <br />Ret—f—i r Ar•rclo.�r,.. r <br />------------- <br />o„,ter <br />PEDESTAL Installed By - Driller .- Pump ContractorOther <br />Concrete Pedestal Dimensions Width k Length k Thick <br />n Christy Box Stove Plpe <br />PUMP Submersible _ Turbine Other <br />HP r Pump Set k 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 INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED <br />TITLE DATE <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />R T M E N T U S E O N L 1 <br />/�- -49 <br />Date <br />_ Date <br />Date <br />Date <br />Area / Y t? Employee ID# / <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth k <br />WELL /PU/.:P PERMIT <br />rn <br />ID <br />A <br />N <br />