WP0040471 - Laserfiche WebLink

Home Browse Search

4 WELLIPUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 NON-REFUNDABLE PERMIT wWW.s OVOC /ehd EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS N CITY/ZIP , ��3 66 m m L QQffjj� D CROSS STREET :V&e 'C APN PARCEL SIZE 2 3�uLAN((JJeASE APPLICATION# A m OWNER NAME Rioao n l� yl \ \ fit{ l PHONE /� N OWNER ADDRESS - `�/ Po• i AcauA / ,X11.� e_ CITY/STATE/ZIP R� �1 A T 3 66 CONTRACTOR y� �_WLIVx r/ PHONE ,L�(J�C \1 -1p4- r-7300 CONTRACTOR ADDRESS-3180 b Wind �sf2e`� o\y L- CITY/STATE/ZIP c `,, ,�[ XLN I CA SUBCONTRACTOR/CONSULTANT�a`\(L(lenPHONE _4Q SUBCONTRACTOR/CONSULTANT ADDRESS30-2)J \0-2) Li 1t� I 4A CITY/STATE/ZIP LICENSE )4.C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER-7 2-0 clo EXPIRATION DATE_L (I I Z02 r� t� BILLING PARTY: OWNER CONTRACTOR _SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other_ ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings 7�Geotechnical of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal LI Cross-Connection Repair ❑ New Pump ❑ Pump Replacement ❑ Pump Repair U Raise Well Casing WELL CONSTRUCTION Drilling Method 1-1 Mud Rotary ❑ Air Rotary t�_Auger ❑ Cable Tool ❑ Push Point ❑ Other 10 Proposed Well Depth�LZft Excavation 6 Z, in diameter CI Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel F] Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth_ ft I)-Neat Cement(94/b bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water ❑ Bentonite(20%solids) ❑ Other t ens �—�-- Grout Placement Method 0 Pumped LI-Free Fall *Other _VJ'C1M,e i� L L] etartlani/ c�cli elerator(name) PEDESTAL Installed By D Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal(I Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible[] Turbine U Other _ HP_ Pump Set _ ft Standing Water Level— ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINI UM 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 7 SIGNED IA LA_ _ TITLE 1'Y 4k DATE - - r A T U D " ' A T M E N T 11 SE J0 N L Y Application Accepted By Date v" Area Employee ID# Grout Inspection By _ Date SPE IAL Well Permit Pump Inspection By Date_—_ _ WAIVER Received Soil Boring Inspection By�. � Date Z�/ � Constructed Well Depth ft COMMENTS PE SC Received heck Amount Permit/ Codes Info B ash ernitte 1 Date Service Re uest# Invoice# Well ID# z P EHD43-06 6/1112019 WELL/PUMP PERMIT