Laserfiche WebLink
WELL/PUMP 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 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 760 Charter Way Stockton/95206 to <br /> CrrYZP <br /> CROSS STREET S. Stockton Street APN 163-2�3II-x-30- 0 PARCEL SIZE 2'4 AcLANDUSE APPLICATION# o <br /> OWNER NAME Mario A. Jaques 141 -Z3, � A <br /> 1_� PHONE 209-482-1191 <br /> OWNER ADDRESS 13286 Willow Glenn Road CITY/STATE/ZIP Stockton/CA /95206 <br /> CONTRACTOR Salem Engineering Group, Inc. PHONE 559-271-9700 <br /> CONTRACTOR ADDRESS 4729 W. Jacquelyn Avenue CITY/STATE/ZIP Fresno/CA/93722 <br /> SUBCONTRACTOR N/A <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE '111i i i C-61 rl D-09 i i Other NUMBER 970772 ExPIRATION DATE 3/31/2020 <br /> DOMESTIC WELL SAMPLING: _General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)I Arsenic(4393) <br /> INTENDED USE DomestiTJPrivate C Irrigation/Agricultural U Industrial ❑Water Quality Monitoring soil Sampling/Characterization <br /> Public Water System <br /> It dRerent from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK n New Well U Replacement Well U Well Alteration/Modification 1I Other <br /> Li Monitoring Well(s) #of wells 1_1 Soil Boring(s) #of bonngs Geotechnical 6 a of borings <br /> i Out-Of-Service Well L Out-Of-Service Well Renewal L)Cross-Connection Repair <br /> New Pump i Pump Replacement L Pump Repair -1 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ..-i Mud Rotary ❑Air Rotary VAuger Cable Tool L Push Point i Other <br /> Proposed Well Depth 5-40 it Excavation 4 8 in diameter I Open Bottom U Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad U Steel n Plastic U Stainless Steel U Other <br /> Grout Seal Depth ft VNeat Cement(94 lb bag/5-10 gal wateo i Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids ❑Other <br /> Grout Placement Method L: PumpedV Free Fall VOther Treml2 Ipe D Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller I Pump Contractor IOther <br /> i i Concrete Pedestal LiDimensions:Width ft Length ft Thick in :1 Christy Box I Stove Pipe <br /> PUMP a Submersible E)Turbine 1 l 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 /> MINIMUM H VANE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED > TITLE Geotechnical Project Engineer DATE 5/9/2019 <br /> Y >6 ?pjy <br /> l QUIN C <br /> y MFN NTs, <br /> T <br /> ARTMEnIr <br /> E? 'RTMENT SE NLY <br /> / Area Employee ID#� <br /> Application Accepted By Date <br /> Grout Inspection By Date SPECIAL WeII Pelmet <br /> Pump Inspection By Date WAIVER Received <br /> 1 / * <br /> Soil Boring Inspection Bye, dvL l �Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received hoc Amount Date Permit/ Invoice# Well IDN <br /> Codes Info s miffed Service Re nest# <br /> t� J Cal(C IS <br /> END 43.06 revised 4/14/18 WELL/PUMP PERMIT <br />