Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 96�b6.6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/clid EXPIRES 1 YEAR <br /> /jFROM DATE ISSUED <br /> JOB ADDRESS 165,R S V\eke ry Am CrTY/ZIP t/4 R•(/,l 6 <br /> CROSS,STREET t�t APN 2241-ZI O'2b PARCEL SIZE 0.3 LAND USE APPLICATION# 0 <br /> OWNER NAME �11.�t 71.1Qy7• t D•tAsN.N.. �7�s?I1rQ/•O PHONE(S6,1 <br /> OWNER ADDRESS VS D S U\SAlk V !�V'G CITYISTATE21P kdal•Lr1 G153 6 I <br /> CONTRACTOR �As{II1� p�r t I1� �hC• PHONE <br /> CONTRACTOR ADDRESS I I9 A I bt S ILA, CITYISTATE21P MOar C/1 Is 357 <br /> SUBCONTRACTOWCONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CITYISTATEIZIP r, <br /> LICENSE )(C-57 U C-61 D D-09 D Other NUMBER b6$1.7,L EXPIRATION DATE <br /> BILLING PARTY: I I OWNER CONTRACTOR I SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:I I General Mineral/Coliform Bacteria(4391)r,Dibromochloropropane(4392) :Arsenic(4393) <br /> INTENDED USEX Domestic/Private n Irrigalion/Agrlcullurai 0 Industrial D Water Quality Monitoring fi Soil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner: Waler System Name contact Name or Phone Number <br /> TYPE OF WORK '(New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> D Monitoring Wells) #of wells 0 Soll Borings) #0 borings 0 Geolechnical #of borings <br /> U Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump U Pump Replacement U Pump Repair U Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodyMud Rotary �O AIr Rotary 0 Auger Oable Tool O Push Point 0 Other <br /> Proposed Well Depth '215,0 it Excavation_12`r In diameter U Open Bottom X Gravel Pack/Gravel Size It I@ In diameter <br /> D Conductor Casing In diameter / Conductor Casing Depth 0 <br /> Well Casing Diameter_k In Thickhess/Gauge/ASTM Sched ZOO _ O Steel o(Ptastic f]Stainless Steel D Other <br /> Grout Seal Depth,/_q0 R 0 Neat Cement(94 lb bag/5-10 gal water) D Sand Cement sack mix/7 gal water <br /> KBentonivta(20°6 solids) O Other <br /> Grout Placement Method I Limped D Free Fell L1 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller Pump Contractor 0 Other <br /> O Concrete Pedestal ODlmensions:Width it Length ft Thick <br /> In O Christy Box U Stove Pipe <br /> PUMP 0 SubmersibleU Turbine O Other HP Pump Set ft Standing Water Level it <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, STAT(: 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 /> WIWIINIDQ!!M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED � TITLE C1 Lam•'K"0 4' DATE <br /> T <br /> ke <br /> /,,,g <br /> \ <br /> r � U <br /> A \ F <br /> r • T <br /> D PARTMENT USE NLY <br /> Application Accepted By Dale��o�L i Area Employee ID#� �� <br /> Grout Inspection B Dale PECIAL Well Permit <br /> p Y <br /> Pump Inspection By Date I WAIVER Received <br /> Soil Boring Inspection By Dale p Constructed Well Depth —it <br /> COMMENTS &K STIA& A116dA gr 14V <br /> eg"ount Date *vice <br /> *Request <br /> EInvolce Well ID# <br /> itted 0' •1o1� 10•q•� <br /> WELL/PUMP PERMIT <br /> EHD43-06 N11/2019 I <br />