WP0039798 - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)469.3420 NON-REFUNDABLE PERMIT _ www.ejjgcfv.fqr-.-/ehc1 _ EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS .�2.Co .rarnt L�r�C Qt CITWLP Tr_GIc. �..95'3"1b m CROSS STREET C` �OY% - ` APN _ n /� Y l)j_i Z 3'�S�y� O � PARCEL SIZE L-ANO USE APPLICATION#_ _- o OWNER NAME COAC'CV�XAf11;\0 V�\Y\�11s `� _ PHONE e N OWNER ADDRESS ,` J A' �6 t AyC`J _. CITY/STATEIZIP SI-2 404\t r A q-1GD(n CONTRACTOR Vim. �Y\�1r\q _ PHONE �9 '�I7^OO CONTRACTOR ADDRESS AX,43 ^�\AJJVY crrYISTATEIZIP S-t6\kC /CA SUBCONTRACTORICONSULTANT MIA �\FSC EYE\`/\ _�. \MSC! PHONE.9ffi0 90kj- lanO SUBCONTRACTORICONSULTANT ADDRESS$ IQ_FW\\00,Y-C� V '% CITY/STATEIZ1PU,k,SC ChACV&WfY\kO(CA (Cl LICENSE Q/-57 0 C$1 0 D-09 D Other NUMBER '120104 EXPIRATIONDATE BILLING PARTY:__ D OWNER 0 CONTRACTOR V/SUBCONTRACTOR/CONSULTANT DOMEsrlc WELL SAMPLING:G General Mineral/Coliform Bacteria(4391)ri Dibromochlompmpane(4392)0 Arsenic(4393) J .INTENDED USE 0 DomesticlPrivate 0 Irrigation/Agricultural D Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization 0 Public Water System It different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK 0 New Well 0 Replacement Welt 0 Well Alteration/Modification U Other _ 0 Monitoring Well(s) 0 o wells &/Sol[Boring(s) k #of borings 0Geotechnical _ 0ofboring3 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair 0 New Pump _ D Pump Replacement_D Pump Repair __ 0 Raise Well Casing WELL CONSTRUCTION Drilling Method Mud Rotary Nr Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other Proposed Well Depth"A S; ft Excavation --- _. in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter 0 Conductor Casing_. In diameter I Conductor Casing Depth It 0. Well Casing Diameter _ in ThickneyGauge/ASTM Schad D Steel D Plastic 0 Stainless Steel 0 Other Grout Seal Depth!_It 8!Neat Cement(94 Ib bag/5-10 gal watch 0 Sand Cement sack mW7 gel water 0 Bentonke(20%solids) ❑Other Grout Placement Method 0 Pumped 0 Free Fall 0 Other _ _ _ 0 Retardant/Accelerator(name) _ PEDESTAL Installed By 0 Driller 0 Pump Contractor ❑ Other-__- 0 Concrete Pedestal❑Dimensions:Width`it Length ft Thick In D Christy Box 0 Stove Pipe Pump _ 0 Submersible0 Turbine_0 Other _ _ HP Pump Set_ If Standing Water Level n l 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. Ml 8 HOUR A OTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9r53-7697 SIGNE c TITLE JtGCF LVW\NGGV DATE 7 (vo --• --^— — - - -71 i PAY --- `�� - -S,�N J 2019 - FNVOgQUIN rl -lit; rh/ROV COUNT — iI I 7-7- — - - I li ZA TMENT U E NLY A Application Accepted By / _ _ ate Area Employee ID#/�4 Grout Inspection By- Date—__ U SPECIAL ell Permit Pump Inspection By _ Dale @ /j/�j/� IJ WAIVER Received Soil Boring Inspedlon By —__—.--— Dale � Ir _!. ,r Constructed Well Depth ft COMMENTS PE SC Racelved hec Amount PermiU _ �_._ y1— rvice Re est# Invoice# Wen ID# C -t ?_ ) ! / - Remitted.--; Date ga - -- EHO 43.06 B!1 V2070 WELL/PUMP PERMIT