Laserfiche WebLink
\�t a <br /> 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 /> w <br /> JOB ADDRESS CrtY21P m <br /> CROSS STREET � � APN PARCEL SIZE'�h LAND USE APPLICATION# A <br /> OWNER NAME .' ' u L-A PHONEF,h ur <br /> c 156 ;�Z?, <br /> OWNER ADDRESS , CnY/STATE21P,��,M�Ye... ._ 11 <br /> 7-, <br /> CONTRACTORPHONE e _ SfJI <br /> a <br /> CONTRACTOR ADDRESS fr 1 aPyk CITY/STATEIZIP <br /> SUBCONTRACTORICONSULTANT t'R��� i-��'���5� PHONE J Cs <br /> SUBCONTRACTORICONSULTANT ADORE SS n awe CITY/STATEIZIP A aai A P;zT_� <br /> LICENSE V161,57 D C-61 D D-09 ❑Other NUMBER r'1 6 EXPIRATION DATE <br /> BILLING PARTY: D OWNER \0-CONTRACTOR D SUBCONTRACTORICONSUL- F7-'TAANTT <br /> DOMESTIC WELL SAMPLING:D General Mineral/Coliform Bacteria(4391)D Dibromochloropropane(4392)D Arsenic(4393) <br /> INTENDED USE D Domestic/Private D Irrigation/Agricultural D Industrial D Water Quality Monitoring keSoll 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 Sol]Boring(s) #of borings b-,69-otechnical #of borings <br /> D Out-Of-Service Well ❑Out-Of-Service Well Renewal D Cross-Connection Repair <br /> D New Pump D Pump Replacement 7 Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION � <br /> Drilling Method D Mud Rotary C Air Rotary D Auger D Cable Tool )E"Kush Point C Other <br /> Proposed Well Depth it 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 7 Plastic D Stainless Steel D Other <br /> Grout Seal Depth1W fteat Cement(94 Ib bag15-10 gal wafer) -1 Sand Cement sack mix/7 gal water <br /> D Bentonite(20%solids) C Other A� <br /> Grout Placement MethodWfumped C Free Fall Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By D Driller ❑Pump Contractor 7 Other <br /> U Concrete Pedestal❑Dimensions:Width ft Length It Thick in L Christy Box L Stove Pipe <br /> PUMP I I Submersible I Turbine I Other HP Pump Set ft Standing Water Level 06 c <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE ?n <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED L4C.E 1 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE N4 0 /R/00 <br /> WORKERS COMPENSATION LAWS. ������GGGGGG j <br /> MINI M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 h p pgRT T[�Np�, <br /> SIGNED TITLE � �,\9Wklt�.4� DATE <br /> Hit 1i <br /> P9 TMENT U E ONLY <br /> Application Accepted By ateyA IT <br /> Area-L% Employee ID#vi�4 <br /> Grout inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date 7A Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permitl Invoice# Well ID# <br /> Codes Info B Cash Remitted S rvice Re uest# <br /> EHD43-06 6/11)8119 (W. <br /> WELL(PUMP PERMIT <br />