Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HA2ELTON AVENUE-STOCKTON CA 95206-6232(208)468-3420 <br /> NON-REFUNDABLE PERMIT www.sisov.org/ohd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOBADDRESs 1 Ul.%1 S. �.L;�yY1\CAC.yS CITYIZIP TTbc�{ 5��1 17i <br /> CROSS STREET VV-SHJ�� ?K OC.(� �APN �0a-a5Q-2li-W�IRCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME jA b�G_v\ fi lJa'�r\Gv(\�V��`�N",VVI..__ PHONE <br /> OWNER ADDRESS \2\'1 It11b `D'�'�`�'nr�G�J 1�� CITYISTATE/ZIP <br /> CONTRACTOR V W w\"\y�q PHONE Z.�,'y\OZ1-17Od <br /> CONTRACTOR ADDRESS SA32) CITYISTATEIZIP G-A ICA <br /> SUBCONTRACTORICONSULTANT \� CC..`iiJQ PHONE �klp <br /> b7Sal; <br /> SUBCONTRACTORICONSULTANT ADDRESS %%Q E1A1VcJ.�Cr A-0 r, lli:Ne. CITYISTATE/ZIP W. al;X- NIM ICA 1'15\005 <br /> LICENSE .t7C-57 ❑C-61 Ci �J <br /> 0-09 ❑Other NUMBER-T -09Z' ExpIRATION DATE <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR liABCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED UsE ❑Domestic/Prtvate C Irdgation/Agricultural D Industrial ❑Water Quality Monitoring 0 Soil Sampling/Characterization <br /> ❑Public Water System <br /> If dI ferenl from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well D Replacement Well 0--//Well Alteration/Modification ❑Other <br /> 0 Monitoring Well(s) #of wells Q Soil Borings) 0 o bodnoa Geotechnical 0 o boAnys <br /> ❑Out-Of-Service Weil 0 Out-Of-Service Well Renewal ❑Crass-Connection Repair <br /> ❑New Pump ❑Pump Replacement D Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑/ylud Rotary 0 Air Rotary EV/Auger ❑Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Apth _ft Excavation l_in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size In diameter <br /> 0 Conductor Casing In diameter I Conductor Casing Depth ft <br /> Well Casing 01ameter-&-in Thickness/ auge/ASTM Schad ❑Steel ❑Plastic C Stainless Steel 0 Other <br /> Grout Seal Depth 30"'1 ft Thickness/ <br /> Cement(94 Ib baglSlO gal water) ❑Sand Cement sack mW7 gal water <br /> D Bentonite(20%solids) ❑Other <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller ❑Pump Contractor ❑ Other <br /> D Concrete Pedestal❑Dimensions:Width ft Length ft Thick in 0 Christy Box C Stove Pipe <br /> uMP ❑Submersible❑Turbine ❑Other HP Pump Sel ft Standing Water Level ft <br /> 1 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 CO �EN ATIONLAW <br /> V <br /> ftJlM 8 HOU DE OTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)9 3-7 97 <br /> SIG D TITLE A \y\�rDATE C1 <br /> I I I I <br /> I <br /> I I I <br /> If Y1WENT <br /> CElyEL) <br /> 20 2019 <br /> J QUIN COUNTY <br /> I I ! I.J ENRN ENTAL <br /> I EPARTI4IENT <br /> � I <br /> 1 , - <br /> P� TMENT U E O LY <br /> Application Accepted By ate C�7�sy� Area_�� Employee ID#71 � <br /> Grout Inspection By44 -. Date ��I Lc t/, ❑ PECIAL WeII Permit <br /> Pump Inspection By Dale — ❑ WAIVER Received <br /> Sol]Boring Inspection By Date_ Constructed Well Depth ft <br /> COMMENTS _ -- <br /> PE SC Received I It cha Amount Date Permit/ invoice# Well ID# <br /> Codes Info BA ash Remitted iceReauest# <br /> EMD 43-M 5111/2019 WELL IPUMP PERMIT <br />