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.sjgOy.OPg/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITY/ZIP <br /> D <br /> CROSS STREET( !�J^,Q c_^APN�3 Q PARCEL SILEt-0J1 LAND USE fAP�PLIICATIOONN## Q o <br /> OWNER NAME 1 / PHONq` 3. / 7�+/ 1O c <br /> OWNER ADDRESS '/,/'�/� �/� CITY/STATE/ZIP Ja� <br /> CONTRACTOR /L" l PHONE <br /> CONTRACTOR ADDRESSCITY/STATE/ZIP ­_--s <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE57 61 n D-09 ❑ Other NUMBER a�� EXPIRATION DATE/ <br /> BILLING PARTY: OWNER I CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)i. Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE omestic/Private ❑ Irrigation/Agricultural ❑ Industrial a 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 /kilew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ew Pump ❑ Pump Replacement ❑ PUrnp Repair ❑ Raise Well Casing <br /> WELL CONSTR CTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool El Push Point ❑ Other <br /> Proposed Well Depth_eZQft Excavation in diameter ❑ Open Bottom Jorravel Pack/Gravel Size_ I in diameter <br /> ❑ Conductor gasing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched GL Zq7 ❑ Steel,,AoPlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth .Left ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Oump Contractor ❑ Other <br /> El Concrete Pedestal❑Dimensions:Width ft Length _ ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> rPuMP submersible❑ Turbine ❑ Other HP Pump Set ZK&ft Standing Water Level. -It <br /> 1 HEREBY CEfRTIFY 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 /> MINI U NCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-.76%7 <br /> SIGNED ��� TITLE DATE < <br /> E P R T M E NfUEN L YApplication Accepted By DateArea Employee ID#Grout Inspection By Date PECIAL Well Permit <br /> Pump Inspection By DateWAIVER Received <br /> Soil Boring Inspection By . Date Constructed Well Depth �Lft <br /> COMMENTS V <br /> PE SC Receivedheck# Amount Permit/ ^ <br /> Codes Irito B s h lRemitted Date Service Request# Invoice# �r <br /> ?p -- <br /> �Z <br /> W QO �OrL AQ <br /> Neem� N <br /> EHD43.06 6/11/2019 ELS RMIT <br />