Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT www.siqov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS if P AYCAV CITY/ZIP m <br /> CROSS STREErAfr r VG� �/� D <br /> APN PARCEL SIZE i LAND USE APPLICATION# <br /> OWNER NAME n ' �t v,� ??s����,, u ) b <br /> PH�ONEE� j--ie, <br /> OWNER ADDRESS '�� ITY/STATEIZIP— ' Y .. 0 �_nlV <br /> 7 <br /> CONTRACTOR PHONEg ') 0y <br /> oma+, <br /> C /.0 <br /> �` <br /> CONTRACTOR ADDRESS y �'+ f.�y� 6Y'7 CITY/STATE21P <br /> SUBCONTRACTOR/CONSULTANT I�OA!?J 6/V� .� PHONE a <br /> G c <br /> SUBCONTRACTORICONSULTANT ADDRESS 4150 t5w5 p CITYISTATE/7JP Mot APz <br /> LICENSE �C-57 D C-61 D D-09 DDOthef NUMBER 1� EXPIRATION DATE <br /> Tr "— <br /> BILLING PARTY: 0 OWNER \0"CONTRACTOR D SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE D DOmestr/PrtVate D Irrigation/Agricultural D Industrial D Water Quality Monitoring oil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK D New Well D Replacement Well D Well Alteration/Modification D Other <br /> D Monitoring Well(s) #of wells 0 Soil Borings) #of borings L�<eotechnlcal #of borings <br /> D Out-Of-Service Well D Out-Of-Service Well Renewal D Cross-Connection Repair <br /> 0 New Pump D Pump Replacement 7 Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION � <br /> Drilling Method D Mud Rotary C Air Rotary 7 Auger D Cable Tool U ush Point C Other <br /> Proposed Well Depth ft Excavation in diameter 7 Open Bottom D Gravel Pack/Gravel Size in diameter <br /> I I Condu or Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Diameter�in Thickness/Gauge/ASTM Schad 7 Steel 3 Plastic D Stainless Steel D Other <br /> Grout Seal Depth ft �I�e�at ft 95Cement(94 Ib bagl5-10 gal water) -1 Sand Cement sack m1rl7 gal water <br /> D Bentonite(20%solids) C Other <br /> Grout Placement MethodR*"�umped C Free Fall Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller D Pump Contractor J Other <br /> U Concrete Pedestal L1Dimensions:Width ft Length ft Thick in L Christy Box L Stove Pipe we <br /> PUMP I I Submersible I Turbine I Other HP Pump Set ft Standing Water Level ft Iv'7�M <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN �1 <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 1 AM IN COMPLIANCE WITH ALN <br /> WORKERS COMPENSATION LAWS. v6� <br /> MINI!n18 /v HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697%91 J� <br /> � 4 <br /> SIGNED TITLE ��r"1i 91a"kiy-pe DATE <br /> N <br /> F qR��NAY <br /> NT <br /> fl L4 I <br /> ,1 T ENT UE NLY QJ <br /> Application Accepted By ate 1 Area Employee ID#A& <br /> Grout Inspection By Date If ❑ SPECIA Well Permit <br /> Pump Inspection By Date e� ! ❑ WAIVER Received <br /> Soil Boring Inspection By Apte �t9 �� Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permitl Invoice# Well ID# <br /> Codes Info 13y^ Cas Remitted rvi eRe uest# <br /> EHD43-08 8111]2019 �D�a .s.,�/ WELL]PUMP PERMIT <br />