Laserfiche WebLink
U WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REEuBLE PERMIT WWW.S OV.or /ehd I EXPIRES 1 YEAR FROM DATE ISSUED <br /> Cn <br /> JOB AD R 5S Ao -ACITY/ZIP m <br /> CROSS STREET (//S/`�ll�( /� APN PARCEL SIZE LAND W APPLICATION# o <br /> A <br /> G. /G <br /> OWNER NAME �^'/��f 2�! PHONE <br /> -CA <br /> OWNER ADDRESS 66 CITYIS7AT 21P JSISS <br /> CONTRACTOR 'TC 2 E e�(\P\r PHONE/I' V' <br /> �! `� 1� —T�` <br /> CONTRACTOR ADDRESS�D Tr�� f\°Y�6y �� �U.\� CITY/STATE/ZIPom 6 <br /> SUBCONTRACTORICONSULTANT l_YnCJrJ� � PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESSOhl a INCITYISTATE21P `R /Z R 1 <br /> LICENSE C-57 0 C-61 D D-09 0 Other NUMBER EXPIRATION DATE 61 <br /> NO! <br /> BILLING PARTY: 0 OWNER 0 CONTRACTOR 0 SUBCONTRACTOR/CONSULTANT O <br /> DOMESTIC WELL SAMPLING:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)D Arsenic(4393) <br /> INTENDED USE 0 DomesticfPrivate 0 Irrigation/Agricultural 0 Industrial 0 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 0 New Well 0 Replacement Well 0 Well Alteration/Modification 0 Other <br /> 0 Monitoring Well(s) #of wells 0 Soil Borings) #of borings Geotechnical #of borings <br /> 0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement 7 Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION � <br /> Drilling Method 0 Mud Rotary C Air Rotary 3 Auger 0 Cable Tool VKU'sh Point C Other <br /> Proposed Well Depth It Excavation in diameter 7 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br /> I I Cord or Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad 7 Steel 7 Plastic 0 Stainless Steel D Other <br /> Grout Seal Depth It ft' eat Cement(94/b bag,5-10 gal water) -1 Sand Cement sack mixl7 gal water <br /> 0 Benton' (20%solids) C Other <br /> Grout Placement Method RITumped C Free Fall 0 Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 7 Other <br /> D Concrete Pedestal UDimensions:Width It Length ft Thick in L Christy Box L Stove Pipe <br /> PUMP I I Submersible 1 Turbine I 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 /> MINIM 48 H ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TITLE,T_- �lr\�t�I�('V DATE <br /> YNj�N <br /> 44A, <br /> ��VFO <br /> /y <br /> 4r /01S <br /> 7'y^CY <br /> TM'El NT <br /> EPARTMENT S ONLY <br /> Application Accepted By ~ Date Area Employee ID#�C �� i�7 <br /> Grout Inspection y Date ❑ PECIAL Well Permit <br /> Pump Inspection By Date 1 WAIVER Received <br /> Soil Boring Inspection ByC, Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit] <br /> Codes Info Cas Remitted Date Service Re uest# Invoice# Well ID# <br /> EHD43-06 6/11/2019 - /Dj,n2—?,To/7 WELL/PUMPPERMIT <br />