Laserfiche WebLink
' t <br /> WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1w'YEAR FROM DATE ISSUED <br /> JOBADDRESS T n\V 5 wit. Fpeg CITY/ZIP U Iv r-Ii <br /> nn i —dF—W sTpac'� wN n <br /> CROSS STREET tAM119i�— 'NM' APN� PARCEL SIZE AND 9EiJAP�P,LLIICATIO�yNI#,Q �1 A <br /> OWNER NAME C1VVCttftr4S 1y%t —\« \O 7GW L�C,�X PHONE �.v\ `1.10" J�� <br /> OWNER ADDRESS Vo 710Aa CITY/SSTAATE/yZIP Slt(3'r--Wr4. CA °157.0 <br /> CONTRACTOR ` PHONE __ p <br /> CONTRACTOR ADDRESS' CITYISTATE01' 6 <br /> ... SUBCONTRACTOR _Ck6jLr>0 �N7�A,RONIMG.IVITPI[.-. PHONE916-638-1169 <br /> SUBCONTRACTOR ADDRESS 3000 Duluth Street CITY/sTATE/ZIP West Sacramento,CA 9591 <br /> LICENSE (C-57 '-I C-61 a D-09 L Other NUMBER 938110 EXPIRATION DATE SeRL 30th.2019 <br /> DOMESTIC WELL SAMPUNG:! General Mineral/Coliform Bacteria(4391)11 Dibromochloropropane(4392)i i Arsenic(4393) N <br /> INTENDeo UsE n DomesticlPrivate ❑Irrigation/Agricultural a Industrial n 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 n New Well 1 Replacement Well Well Alterallon/Modiftcation L Other <br /> MonitoringWell(s) #of wells ❑SoilBo6ng(S) xerbedngs �(Geotechnicalm4'fborings <br /> Out-Of-Service Well ❑Out-Of-Service Well Renewal Cross-Connection Repair m�X IVYwM <br /> New Pump ❑Pump Replacement Ll Pump Repair 1 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method c Mud Rotary :-�Air Rotary ❑Auger ❑Cable Tool 7 Push Point Other V <br /> Proposed Well Depth 10—10 ft Excavation 7_in diameter r,Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad ;,Steel G Plastic i Stainless Steel �Other <br /> Grout Seal Depth_ft Neat Cement(94 Ib bag/5-10 gal wafer) L Sand Cement sack mixf7 gal water <br /> Bentonite(20%solids) n OtherVa *% T'h to <br /> Grout Placement Method a Pumped Free Fall C Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller rl Pump Contractor :-I Other <br /> Concrete Pedestal❑Dimensions:Width ft Length n Thick in C Christy Box i i Stove Pipe <br /> PUMP 141 N❑Submersible C',Turbine Other HP Pump Set ft Standing Water Level R <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 15 <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 DVA CE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE VP Opertations DATE 05/16/2019 <br /> 01 A <br /> / O <br /> D RT NT E NLY <br /> Application Accepted ey Date Area Employee ID# <br /> 1-7 <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date�� �/��h�I�11,/ WAIVER Received <br /> Soil Boring Inspection By Date f _ f" ' Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#1 Amount Date Permitl Invoice# Well ID# <br /> rALO Info ,Cash Remitted Service Re uest# <br /> V 5 <br /> EHD 43-06 revised 4114/16 WELL/PUMP PERMIT <br />