Laserfiche WebLink
s <br /> 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 /> JOB ADDRESS 19 {D�� &V'0 I CITY/ZIP m <br /> CROSS STREET `(l VlD' APN�2`d 1' j jD* A— PARCEL SIZE LAND USE APPLICATION# Cn <br /> p <br /> OWNER NAME tT/4EhvI 4-741? IPP .5'e 1/o" •�t'L 1'e'- PHONE 46 cpyz N <br /> OWNER ADDRESS �Z J f L/ R, CITY/STATE/ZIP 'CcZ/c, �^ <br /> 1 r <br /> CONTRACTOR _�szm_s` ' tK PJHONE..T-2,2-f92 <br /> P <br /> CONTRACTOR ADDRESS I I A �✓`,S '_` Cy�� <br /> ITY/STATE/ZIP I VZ11Q5>iO <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE XC-57 ❑ C-61 ❑ D-09 0 Other NUMBER 4f&'V6,22 EXPIRATION DATE Z49 Z <br /> BILLING PARTY: I OWNER 1 1 CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)1! Dibromochloropropane(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 WORKf New Well ❑ Replacement Well ❑ Well Alteration/Modification 11Other <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 /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method )(Mud Rotary n Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth-2�ft Excavation Z 0 in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameters in Thickness/Gauge/ASTM Sched .2 X70 El Steel Plastic F1 Stainless Steel ❑ Other <br /> Grout Seal Depth X0 ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement /L% sack mix17 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method XPumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By LI Driller Pump Contractor El Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick Jn L1 Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ Other _ HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY 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 MU 8 CE NOTICE REQUIRED FOR IN P�'TI NS -PLEASE CALL(209) 9953-7697 A <br /> SIGNED _ TITLE,`!•_ DATE A <br /> hi op <br /> T <br /> p, <br /> 1 <br /> r <br /> 1' A R T M E N T USE O LY <br /> 2/2 <br /> Application Accepted By °' ____ Date I Area Employee ID#'4vi ,� <br /> Grout Inspection By 1V�I ��_ Date PECIAL Well Permit <br /> Pump Inspection By _ Date WAIVER Received <br /> Soil Boring Inspection By Date ConstructeSI Well Pepth _ ft <br /> COMMENTS 6-6' b S/.1 <br /> PE SC Received chAmount Permit/Codes Ifo B Cash mi ed Date Service Re uest# Invoice# Well ID# <br /> E� )2•l.�o•�a1 p D� <br /> EHD 43-06 6111/2019 WELL/PUMP PERMIT <br />