Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> M I� S23 L m <br /> JOB ADDRESS 1-lQ �>1V� e {� CITY/ZIP m <br /> D <br /> CROSS STREET h S`-V APN A7, 140 33 PARCEL SIZE 2(o.gLAND USE APPLICATION# <br /> LM <br /> m <br /> OWNER NAME . I O PyONE L `IR- SILO (? <br /> OWNER ADDRESS 2 DOOM _ 10 P-j CITY/STATE/ZIP L 4641d{h,, (,.A ?S 21A <br /> 1{ T s <br /> CONTRACTOR k PriAl�V-4 PHONE ! � ��ss��Z� <br /> CONTRACTOR ADDRESS I A 1 IIS cs a CITY/STATE/ZIP oJtsT s / CA <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER ? EXPIRATION DATE 19 <br /> BILLING PARTY: ❑OWNER ONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑ Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK XNew 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 Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodMud Rotary ❑ Air Rotary ❑ Auger ❑ C able Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth 358 ft Excavation 2-AD in diameter ❑ Open Bottom )(Gravel Pack/Gravel Size, in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> 2 <br /> Well Casing Diameter1in Thickness/Gauge/ASTM Sched 00 ❑ Steel (Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth-Sd ft ❑ Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method Pumped ❑ 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 D Submersible❑ Turbine ❑ 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 /> MIN�J1�11.48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)9y53-7697 Q <br /> SIGNED `��s TITLE X0^1 Ile e— DATE <br /> T <br /> iff0v IV <br /> O N <br /> IR N E <br /> IT <br /> H E AUH <br /> PARTM ENT USE ONLY <br /> c <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By ate ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Ins ection By Date Constr tid Well Depth ft <br /> COMMENTS (� <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash Remitted Date Service Re uest# Invoice# Well ID# <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />