Laserfiche WebLink
I <br /> o I <br /> WELL/PUMP PERMIT <br /> ,SAN JOADUIN COUNTY ENV( NM TAL HEALTH DEPARTMENT 1068 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-5420 <br /> NON-REFUNDABLE PE IT WVJW.SJ(�JOV Orglehd EXP�REfi 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 19 ��� K'(.�r0'" ``� CITYIZIP GIC(P^— _ <br /> D <br /> 0 <br /> /J APN 1110' PARCEL SIZE LAND USE APPLICATION# o <br /> CROSS STREET `(2r h -j I -7 (',,�p m <br /> OWNER NAME <br /> �i-lel�H d /�Ir1�rA�� 1l(d IQhr PHOt1E 6�4- `�O 7z y <br /> OWNER ADDRESS3 3 9 f /"ver �� CITYISTATEIZIP,�S'G��C�'C - <br /> U. PHOE <br /> CONTRACTOR <br /> CONTRACTOR ADDRESS_ <br /> 17 CITYISTATEIZIPOL�QS3O <br /> PHO E <br /> SUBCONTRACTORICONSULTANT <br /> CITYISTATE/ZIP <br /> SUBCONTRACTORICONSULTANT ADDRESS / <br /> NUMBER (B L Vh 77 EXPIRATION DATE 1 09 Z I <br /> (CENSE flj(C-G7 I]C-61 U D-09 D Other - <br /> BILLING PARTY: IOWNER iI CONTRACTOR SU13CONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:I I General Mineral/Coliform Bacteria(4391)i,Dibromochloropropane(4392)�I �AmLnlr4393) <br /> INTENDED USE n DomeslidPrivate IXrrlgation/Agricullural O Industrial D Water Quality Monlloriny D Sal Sampling/Characterization — <br /> n Public Water System_ yyater System—Neme Conled N me or Phone Number <br /> IT diff—M Irom O—ec <br /> TYPE OF WORT( X New Well U Replacement Well U Well Alteration/Mod iOcaUon 0 Other I #or bodnys <br /> p Monitoring Wells) <br /> #of wells 0 Soil Boring(s) #of borings ❑Geo`echnical <br /> n Ou(-Of-Service Well n Out-Of-Service Well Renewal 0 Cross-Connectlo� Repair <br /> n New Pump D Pump Replacement 0 Pum Repair <br /> 0 Raise Well Cast <br /> I <br /> WELL CONSTRUCTION <br /> Drilling Method ()(Mud Rotary D Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other in diameter <br /> Proposed Well Depth_j�_ft Excavation z�in diameter 0 Open Bottom U Gr(tvel Pack/Gravel Slze <br /> D Conductor Casing in diameter I Conductor CasI15g Depth <br /> Steel Plastic n Stainless Steel U Other. <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched t2 D Sand Cement (�I sack mW7 gal water <br /> Grout Seal Depth s ft n Neal Cement(94 Ib bag/5.10 gal wafer) <br /> D Bentonite(20%solids) U Other <br /> Grout Placement Method Pumped Lt Free Fall U Other <br /> p Retardant/Accelerator(name) <br /> PEDESTAL Installed ey D Driller ump Contractor 13 Other <br /> D Concrete Pedestal I]Dimenslor s:Width fl Length Il Thick in U Christy Box U Stove Pipe <br /> It Standing Water Level R <br /> PUMP _ <br /> I]Submersible)I Turbine 0 Other HP Pump Set <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE -DIONE IN ACCORDANCE WITH SA <br /> JOAQUIN <br /> THE$TATE ICALI CALIFORNIA CONTRACTORS LAWS, AND RULES AND <br /> ICEINSE BOARD ANDTHI ALSO IAT.I AMT INCOMPLIANCE YREQUIRED LICENSE <br /> WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> R�N11wN�a_�QNS-PLEAS CALL(209)953-7697 r/�� <br /> MINIMU 8 CE NOTICE REQUIRED FO1 <br /> TITLE <br /> DATE \� 1h A <br /> SIGNED_ - <br /> Fo <br /> _ — < H D N� <br /> R <br /> T <br /> 1 N <br /> D`E ARTMENT USES O LY <br /> Area Employee ID#r� <br /> Application Accepted By. I PECIAL Well Permit <br /> Grout Inspection By Date <br /> Date WAIVERReceived <br /> Pump Inspection By ft <br /> Soil Boring Inspection By <br /> Dale Constructed Well Depth <br /> COMMENTS <br /> Amount PermiU <br /> PE St Invoice# Well ID# <br /> Received he Dale iRe uest# <br /> Codes to B Cash� elnl ad Service <br /> b 12•lw•t�1 PO <br /> WELL/PUMP PERMIT <br /> EHD43.00 5r1V2019 <br />