Laserfiche WebLink
J <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT IBES EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4W3420 6. <br /> NON-REFUNDABLE PERMIT tNy1IW.S OV.Of /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> ZQ /,/ to <br /> JOB ADDRESS vu D t/1 S CI10P m <br /> C V�/ SED <br /> CROSS STREET PNDOJ PARCEL SIZE rAND APPLICATION <br /> OWNER NAME (n�e <br /> ��"TTT��� PHONE I 1 I 1 IU <br /> �( <br /> OWNER ADDRESS � ll CITYISTATEMP <br /> CONTRACTORDr*t\\tr-J PHONE /a 07] <br /> CONTRACTOR ADDRESS T— Q� / TC / T <br /> 7�✓ <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATEIZIP <br /> LICENSE XC-57 C-61 D-09 -:Other NUMBER )q�B Ex%RATION DATE-7:3I--?Q <br /> BILLING PARTY: _,.OWNER -:CONTRACTOR - SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: _;General MineraVColiform Bacteria(4391)❑Dibromochloropropane(4392) Arsenic(4393) '*-4 <br /> INTENDED USE DomestidPnvate Irrigation/Agricultural Industrial C Water Quality Monitoring Soil Sampling/Characlen2ation ®A •►'�wp� <br /> n Public Water System <br /> If di ferent from Owner: Water Systom Name Contact Name or Phone Number <br /> TYPE OF WORK New Well 1 1 Replacement Well :;Well Alteration/Modificabon _!Other <br /> Monitoring Well(s) #of wells -.Soil Bonng(s) a or bodnW '._Geotechnical a of b.nnp 26 <br /> Out-Of-Service Well -Out-Of-Service WEII Renewal Cross-Connection Repair �-'rY Oq <br /> New Pump X. PumpReplacement Pump Repair Raise Well Casing F CIIA� <br /> WELL CONSTRUCTION �/`/ <br /> Drilling Method Mud Rotary Air Rotary "-Auger Cable Tool Push Point t, Other DAP'�RT <br /> Proposed Well Depth ft Excavation in diameter Open Bottom -1 Gravel Pack/Gravel Size in diameter MFNr <br /> i Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad :.I Steel ❑Plastic C Stainless Steel -Other <br /> Grout Seal Depth It �]Neat Cement(941b beg/5-10 gal wafer) Sand Cement sack mW7 gal water <br /> Bentontte(20%solids) L-Other <br /> Grout Placement Method _Pumped G Free Fag Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor - Other <br /> -Concrete Pedestal::Dimensions:Width ft Length ft Thick in C.Christy Box -:Stove Pipe <br /> PUMP A Submersible_Turbine L Other HP Pump Set ft Standing Water Level_gQ ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL 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 /> IYIINI UAh 48 HO ADVk. NOTICE REQUIRED FOR I ' ECTIIONS-PLEASE CALL(20, <br /> SIGNED TITLE Ll DATE <� � <br /> W N e <br /> S <br /> fi <br /> ',/��I/,I. TMENT UU_I <br /> Application Accepted By-CyCT aten2LIArea l L 1 Employee ID# V <br /> Grout Inspection By Dete El SPECIAL Well Permit <br /> Pump Inspection By Date I 7 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info B Cash emitted Date Sery Re ueat# Invoice# Well ION <br /> I / <br /> i <br /> EHD 43-06 5/112019 � - // WEL(PUMP PERMIT <br />