WP0040053 - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 NON-REFUNDABLE PERMIT �1www.sjgov.org/ehd EXPI E/Sl 1 YEAR FROM DATE ISSUED JOB ADDRESS Z - a"N CITY/ZIP �r m yr CROSS STREET �� V/; D C2/ �J�'�J � APNPARCEL SIZE � LAND USE APPLICATION C#� OWNER NAME ,OcJ PHONE %U2 [ J UCl/ tNi� OWNER ADDRESS //JJ � �y! / / // CITY/STATE/ZIP !/ �O ^7 CONTRACTOR A �� v�ox. �/II!(� lI�'1 PHONE`?'3 Ci� CONTRACTOR ADDRESS 0 CITY/STATE/ZIP SUBCONTRACTOR/CONSULTANT lr ( C7/�� V„'A PHONE SUBCONTRACTOR/CONSULTANT ADDRESS CCrry/STATE/ZIP LICENSE �-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER J 77J� EXPIRATION DATE �7 7 BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE omestic/Private ❑ Irrigation/Agricultural _-I Industrial ❑ 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 a Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells 11 Soil Boring(s) #of borings Geotechnical #of borings I Out-Of-Service Well 11 Out-Of-Service Well Renewal 1.1 Cross-Connection Repair XNew Pump 11 Pump Replacement ❑ Pump Repair Raise Well Casing WELL CONSTRUCTION Drilling Metho0,:!6 Mud Rotary ❑ Air Rotary ❑ Auger 1:1 Cable Tool n Push Point Other � Proposed Well Depth ft Excavation �- in diameter 7 Open Bottom .Gravel Pack/Gravel Size in diameter o Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter K in Thickness/Gauge/ASTM Sched 2 ZFG u Steel -Plastic ❑ Stainless Steel i-1 Other Grout Seal Depth /,?1 ft I I Neat Cement(94 Ib bag/5-10 gal water) >Sand Cement -40 ,-3 sack mix17 gal water Li Bentonite(20%solids) u Other Grout Placement Method4 Pumped ❑ Free Fall a Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By� , Driller 11 Pump Contractor -� Other ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP ,ejSubmersible[] Turbine ❑ 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. MINIMUM 48 HO R AANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209) 9(5�3-76/9�7 / SIGNED /�Y/^ `/'l/t"_' TITLE �Ct/ DATE CJ t*A<2 1 low . -u—mc ------- j-3 r QI Cut Ty EW R N NT TFIT-1tv LT D PA TMENT US /N LY Application Accepted By ti Date C Area Employee ID# Grout Inspection By Date e SPECIAL Well Permit Pump Inspection By PCCkA c"�;(n C^ar�:� (�.`t Date Z010q c2% WAIVER Received Soil Boring Inspection�By Date C.olnstru d Well Depth ft COMMENTS �l �r PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Ifo A QV Cash R mitted Service Re uest# z 19 lA 6V§3 9 L �9 �li1 L I 3 E D 43-06 6/11/2019 & WELL/PUMP PERMIT