Laserfiche WebLink
WELL/PUMP PERMIT <br /> t 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 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 218 Hemlock Avenue CITyIZIP MANTECA/95337 m <br /> D <br /> CROSS STREET W Center Street APN 217-110-08 PARCEL SIZE 011A­3 LAND USE APPLICATION# O <br /> M <br /> m <br /> OWNER NAME Sukhji Mann PHONE m <br /> OWNER ADDRESS 3312 Blaker Ave CITY/STATE/ZIP CERES/CA/95357 <br /> CONTRACTOR West Coast Exploration PHONE (209)985-7541 <br /> CONTRACTOR ADDRESS 1540 Roosevelt Avenue CITY/STATEIZiP ESCALON/CA/95320 <br /> SUBCONTRACTOR/CONSULTANT CTE CAL,INC. PHONE (209)543.1799 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 4230 Kiernan Avenue,Suite 150 CITY/STATE/ZIP MODESTO/CA/95356 <br /> LICENSE it C-57 ❑C-61 D-09 ❑Other NUMBER 870/61 EXPIRATION DATE 01/31/2020 <br /> BILLING PARTY: C OWNER ❑CONTRACTOR B SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:-General Mineral/Coliform Bacteria(4391)-:Dibromochloropropane(4392)D Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural ❑Industrial 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 ❑New Well D Replacement Well ❑Well Alteration/Modification ❑Other <br /> MonitoringWell(s) #of wells ❑SoilBoring(s) Cofbodngs ®Geotechnical / 0ofborings <br /> Out-Of-Service Well ❑Out-Of-Seryice Well Renewal ❑Cross-Connection Repair <br /> -_New Pump Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary ❑Air Rotary 0 Auger 7 Cable Tool D Push Point ❑ Other <br /> Proposed Well Depth 10 ft Excavation 4 in diameter ❑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 ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft >Qqeat Cement(94/b bag/5-10 gal water) T Sand Cement sack mW7 gal water <br /> 7 Bentonite(20%solids) ❑Other <br /> Grout Placement Method C Pumped ree Fall ❑Other -' Retardant/Accelerator(name) <br /> PEDESTAL Installed By Drill r Pump Contractor Other <br /> Concrete Pedestal Dimensions.Width It Length It 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 <br /> �48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> /C6 <br /> SIGNED i w151��(( all4 TITLE Staff Geologist DATE 8/7/19 <br /> SEE ATTACHED LO CAT r0 MAY <br /> FcF��Nr <br /> G F® <br /> Qum, <br /> E�rr�,g' <br /> MFHr <br /> DEPARTMENT U E NLY <br /> Application Accepted By Date Area Employee ID#�� <br /> Grout Inspection By Date ❑ SPECIAL WeII Permit <br /> Pump Inspection By Date -`,4- WAIVER Received <br /> Soil Boring Inspection By Date / Constructed Well Depth It <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info ash Remitted ice Re uest# <br /> EHD 4}pg 6/11/2018 � ` -7, WELL/PUMP PERMIT <br />