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 <br /> 1YEAR FROM DATEISSUED <br /> JOB ADDRESS L 37 • 1UN CITY/ZIP N, Gad v�93W / <br /> CROSS STREET C N ,�/(�p/►y APN���,y^_, �/�/ _ ✓ O PARCEL SIZE1.g2 LAND USE APPLICATIONZ# <br /> OWNER NAME �Ilil ,`�/M�►ol`1 �S 3O' I� PHONE �03I/►�(y.�. K/8l0 �? <br /> OWNER ADDRESS O - +'v X 9;41!01 CITY/STATE/ZIP 201-92z.�l✓ �(]`� <br /> CONTRACTOR � \ <br /> i 7 DVI I G PHONE <br /> CONTRACTOR ADDRESS <br /> 11 1 CITY/STATE/ZIP Gav <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP '�/�w} <br /> LICENSE )(C-57 D C-61 ❑ D-09 D Other NUMBER EXPIRATION DATE " <br /> BILLING PARTY: ❑OWNER U CONTRACTOR D SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)U Dibromochloropropane(4392)LI Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring D 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 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 /> D New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method XMudRota ❑ Air Rotary ❑ Auger 11 Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth -300 ExcavationII l� in diameter ❑ Open Bottom Gravel Pack/Gravel Size in diameter <br /> D Conductor rCasing in diameter / Conductor r1 Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 2-00 ❑ Steel XPlastic D Stainless Steel ❑ Other <br /> Grout Seal Depth U0 ft D Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method NPumped ❑ 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 ❑ 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 /> MINIMUM V OTICE REQUIRED FO NS -PLEASE CALL(209L9 -7697 <br /> SIGNED TITLE DATE <br /> Jt <br /> J <br /> 1111A'Y <br /> i <br /> i <br /> H LT D P <br /> ^ DEPARTMENTU E/ 0NLYG <br /> Application Accepted By I�l Date v �� 1 Area Employee ID# moi' <br /> Grout Inspection By Date-11/5/2 o ❑ SPECIAL Well Permit <br /> Pump Inspection By Date Ll WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS at 2,05 <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info By Cash Remitted Service Re ues # <br /> I d 4,w <br /> 14 1 <br /> EHD43-06 6/11/2019 WELL/PUMP PERMIT <br />