Laserfiche WebLink
WELL/PUMP PERMIT <br /> r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1866 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT r, CALL 209 953-7697 FOR INSPECTIONS (/`� EXPIRES <br /> ,,1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ry CITY/Zip.0N mak; {.O <br /> AVV/ �f�' t� t1 m <br /> CROSS STREET�►�/�_M /'�APN/W��,��OTG��O PARCCEELStStZE`�•34F LAND USE APPLICATITION## UL �J o <br /> OWNER NAME F#j"{/T✓ yn O�T���'1�'� � +'•`�4I PHONEUq-1 -? '7f� • 0 ti <br /> OWNER ADDRESS r✓FO^ A• 13 ! CITY/STATE/ZIP — •� <br /> CONTRACTOR J� /1 ONE9/( -37Z- <br /> CONTRACTOR ADDRESS CITY/STATE/ZIPWCy3m <br /> SUBCONTRACTOR ,'ll /"�'� I PHONWCW q-Y1-^j77aa <br /> SUBCONTRACTOR ADDRESS 1133 t � tz r V16" CITYISTAATTE/ZIP�T 4?-4--f Q65&3pZ— <br /> LICENSE C-57 C-61 D-09 Other NUMBER 7020 e EXPIRATION DATE �O ✓T/ <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring X Soil Sampling/Characterization <br /> 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 Other <br /> Monitoring Wells) #of wells Soil Boring(s) #of borings Y Geotechnical 11 of bohngs 1 <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair J <br /> New Pump 1 Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool i Push Point i i Other <br /> FLpposqdIM* DeptAWRI ft Excavation in diameter Open Bottom 1 Gravel Pack/Gravel Size in diameter <br /> 90111111!411-� i Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched Steel Plastic I Stainless Steel Other <br /> Grout Seal DepthJW57) ft X Neat Cement(94 lb bag/5-10 gal wafer) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method XPumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By i Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box 1 Stove Pipe <br /> PUMP Submersible, Turbine Other HP Pump Set It 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 /> MIN UM CE NOTICE REQUIRED FOR i/�jcxpcE-C1TIIONS-PLEASE CALL(209)953- 697 <br /> SIGNED TITL�� DATE54 <br /> C <br /> N <br /> QE ARTMate US <br /> I <br /> Application Accepted By Date /� Area / Employee ID#IL�J4j�`' _- <br /> Grout Inspection By Date If PECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By/vis•#.(�:a"'/Y/f/✓L<C Date i a u/� structed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> odes Info as�I emitted S 'ce Request# <br /> Woo- <br /> EHD43-06 revs d4/14/18 WELL/PUMP PERMIT <br />