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 /> pN <br /> JOB ADDRESS L L I >t 9 �C ��}i i Cr Y21P IBJ c, , m <br /> CUP-fZa <br /> CROSS 1 APN ()!W,, IZO'6� PARCEL SIZEIb,7/ LAND USE APPLICATION# A <br /> m <br /> OWNER NAME D p G ' ,gPHHONE <br /> OWNER ADDRESS \ 6 47 % CITYISTATE/ZIP ✓`�'✓( <br /> CONTRACTOR /U�c I U A✓�c�t 1 L �,� PHONE (21 ft) <br /> CONTRACTOR ADDRESS O Z 1 r�JJ;1y k Vy'" 1 CITY/STATE/ZIP ( (A <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE X C-57 C-61 D-09 ❑ Other NUMBER C;4 ci C C�c I EXPIRATION DATE 5 S 1 Z:.; l <br /> BILLING PARTY: OWNER ❑CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)_1 Dibromochioropropane(4392)_ Arsenic(4393) <br /> INTENDED USE Domestic/Private - Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well Replacement Well ❑ Well Alteration/Modification Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings X Geotechnical s of borings <br /> 0 Out-Of-Service Well ❑ Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump ❑ Pump Replacement ❑ Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION A �7* <br /> Drilling Method Mud Rotary ' Air Rotary Auger n Cable Tool Push Point Other ®l <br /> Proposed Well Depth io- -t c ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size �jQ tJ,j�meter 9 <br /> Conductor Casing in diameter / Conductor Casing Depth ft ���C((�I ® 0/9 <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched Steel :3 Plastic Stainless Steel ❑ Other%SAN 1, <br /> Grout Seal Depth 0 - O ft y:Neat Cement(94 Ib bag15-10 gal water) ❑ Sand Cement sq*' UNTM <br /> Bentonite(20%solids) Other FlL <br /> Grout Placement Method Pumped ❑ Free Fall they Retardant/Accelerator(name) ENT <br /> PEDESTAL Installed By Driller 11Pump Contractor Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP [I Submersible Turbine F-1Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT 1 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. 1 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 H R ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)953-7697 <br /> SIGNED �' - TITLE t,'c L' '�`5 DATE I <br /> V <br /> tn� <br /> F <br /> ESP RTMENT U E NLY �f <br /> Application Accepted By Date t Area C Employee ID#PLO- <br /> Grout <br /> Inspection By Date _ PECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date 4 .J' Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Inf Remitted Service Request# <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />