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.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> f L N <br /> JOB ADDRESS -) LnII W WQSVN,�"q.w c('�1L 1-t? , CITY/ZIP ��O�kLQ 195203 D <br /> CROSS STREET APN 145n3nni PARCELS LAND USE APPLICATION# a <br /> OWNER NAME PHONE <br /> OWNER ADDRESS ' CITY/STATE/ZIP <br /> CONTRACTOR Kelinfelder PHONE 209-981-7755 <br /> CONTRACTOR ADDRESS 2001 Arch Airport POrt,Suite 100 CITY/STATE/ZIP Stockton,CA,95206 <br /> SUBCONTRACTORICONSULTANT V and W Drilling PHONE 209-981-7755 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS 1133 Blackhurst Dr CITY/STATE/ZIP Galt,CA,65632 <br /> LICENSE x C-57 0 C-61 U D-09 J Other NUMBER 720904 E%PIRATION DATE 04/30/2020 <br /> BILLING PARTY: 0 OWNER $0 CONTRACTOR D SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)U Dibromochloropropane(4392)P Arsenic(4393) <br /> INTENDED USE Domestic/Private C Irrigation/Agricultural ._ Industrial D Water Quality Monitoring C Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK U New Well Replacement Well 0 Well Alteration/Modification 0 Other <br /> U Monitoring Well(s) #of wells ❑Soil Borings) #of borings Ilk Geotechnical_3 of borings <br /> 0 Out-Of-Service Well LI Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> ❑ New Pump 0 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method R Mud Rotary 0 Air Rotary M Auger -1 Cable Tool i-i Push Point ❑ Other <br /> Proposed Well Depth Zo_5o it Excavation_6 in diameter D Open Bottom ❑Gravel Pack/Gravel Size in diameter 3�or�gaf_g - <br /> Conductor Casing in diameter / Conductor Casing Depth It Q <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other p' <br /> Grout Seal Depth It Js Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement sack mixn gal water <br /> Bentonite(200 solids) D Other <br /> Grout Placement Method OA Pumped 0 Free Fall 0 Other U Retardant/Accelerator(name) 7 CO <br /> PEDESTAL Installed By ❑ Driller 0 Pump Contractor U Other <br /> Concrete Pedestal❑Dimensions:Width It Length It Thick in I Christy Box C Stove Pipe <br /> Pu MP Submersible-.]Turbine U 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 /> MINIMUM 48 HOUR ApVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED J TITLE Project Professional DATE �2•�Z•1019 <br /> SAt ?D f� <br /> N ��N <br /> P TAS 7-y <br /> MEj yT <br /> ARTMENT USE ONLY ,�y� ,� � <br /> Application Accepted By Date-�`�� Area S/ /�Employee ID# ' <br /> Grout Inspection By Date �� SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date'2/I c=t Ck Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Re uest# <br /> Al A)h <br /> EHD 43-06 6/112019 I^ ^ 1 O D 5 ^ � WELL/PUMP PERMIT <br />