WP0039871 - Laserfiche WebLink

Home Browse Search

WELLIPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 NON-REFUNDABLE PERMIT www.siciov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS Zeta(J l ! W�7�— CITY/ZIP S D CROSS STREET _ APN71 PARCEL SIZE.2ZAND USE APPLICATION# p OWNER NAME /� �/� PHONE OWNER ADDRESS (, (S r CITY/STATE/ZIP CONTRACTOR _ l� PHONES V CONTRACTOR ADDRESS / 11 S/ CITY/STATE/ZIP SUBCONTRACTOR/CONSULTANT``— PHONE SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP LICENSEt C-57 C1 C-61 ❑ D-09 ❑ Other NUMBER � 0 EXPIRATION DATE BILLING PARTY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Wells) #of wells ❑ Soil Boring(s) #ofborings ❑ Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing In diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack m/xl7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible❑ Turbine ❑ Other HP Pump Set_ ft Standing WateF Level 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDAN E 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, MIN HOUR ADVANCE NOILCE RE-QVFOR INSPECTIONS -PLEASE CALL(209))J953-7697 g SIGNED L_�� TITLE_ DATE !�� N� oe q 19 ro o ry r P9, TMENT U E O LY Application Accepted By Date Area Employee ID# Grout Inspection By Date ❑ As Well Permit Pump Inspection By MG*)L► DC7`f Date r�_ D WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS �ffl/1 - PE SC Received eck Amount Permit/ Co s Info B emitted Date Service Request# Invoice# Well ID# x1 EHD 43-06 6/11/2019 WELL/PUMP PERMIT