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 /> LD <br /> JOB ADDRESS �� oix ` CITY/ZIP rArMMV: Cq m <br /> Y� <br /> ) D <br /> CROSS STREET IS c11-t Mot- APN l$Z� 1DO"©� PARCEL SILE"34 rLAND USEQAPPLIICATION# A <br /> OWNER NAME Risr�h 4-�a�kL LC, PHONE_`GniLIT99 N <br /> OWNER ADDRESS (1_Q�"15z AU--C---e CITY/STATE/ZIP p <br /> CONTRACTOR M IaS[ ` u "d I 1 W' I �Mir• �PHONE <br /> CONTRACTOR ADDRESS t be rc, 1114. CITY/STATE/ZIP /1r/�/6d e- b C4 g s3S7 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/SSptTATE/ZIP ? <br /> LICENSE �C-57 ❑ C-61 0 D-09 L1 Other NUMBER �p�(/1DZZ c'EXPIRATION DATE 7'J1 -Z,' <br /> BILLING PARTY: 41OWNER i CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392), Arsenic(4393) <br /> INTENDED USE 0 Domestic/Private Irrigation/Agricultural ❑ Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORKNew Well ❑ Replacement Well 0 Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells 0 Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal LI Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement 0 Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method)(Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point 0 Other <br /> Proposed Well Depth $Ob ft Excavation 2H r in diameter F1 Open Bottom rGravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter t ID in Thickness/Gauge/ASTM Sched V-ZSo kSteel ❑ Plastic ❑ Stainless Steel 0 Other <br /> Grout Seal Depth ft ft CI Neat Cement(94/b bag/540 gal water) YSand Cement 10 •3 sack rnix17 gal water <br /> ❑ Bentonite(20%solids) 0 Other <br /> Grout Placement Method Pumped ❑ Free Fall 0 Other n Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal 0Dimensions:Width ft Length ft Thick in 0 Christy Box ❑ Stove Pipe <br /> PUMP 0 Submersible❑ Turbine 0 Other 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> M M 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 953-769J7p <br /> SIGNED TITLE 0 " III` DATE <br /> C I; <br /> .8 ram ivri I7-V <br /> ARTMENT USE NLY <br /> Application Accepted By Date Area Employee ID# � <br /> Grout Inspection By N Date 61 * ' AECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Ins ection By Date Constructed Well Depth ft <br /> COMMENTS f <br /> PE SC Received he Amount at Permit/ Invoice# Well ID# <br /> Codes info B Cash Remitted Service Re uest# <br /> 20 o a 9 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />