WP0040046 - 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 www.§jgqv.qrg/ehd EXPIRES 1 YEAR FROM DATE ISSUED lQ/. L rr�,I I Tip c' r JOB ADDRESS M D, (`] CITY/ZIP v1 0 CROSS STREET ( • •a 1'r'L� APN ZH 02- D Q ( PARCEL SIZE r LAND USE APPLICATION# o OWNER NAME / JI1� �� W I/VI 6tL PHONE 7 OWNER ADDRESS (� J L` ,�^�/ v )�l 11-4(4 1 L CITY/STATE/ZIP ��'C �� J�y CONTRACTOR �/�J JJ� V I I `� I I 1 PHONE / �/�yv( CONTRACTOR ADDRESS ` G W CITY/STATE/ZIP P,I OR '6C-t V1 L SUBCONTRACTOR/CONSULTANT C�J PHONE SUBCONTRACTOR/CONSULTANT ADDRESS C ITY/ST A TE/ZIP LICENSE C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER l� f—1 '� EXPIRATION DATE �- V BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ 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 ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of b ^;ej,IV 11 Out-Of-Service Well 11 Out-Of-Service Well Renewal 11 Cross-Connection Repair �s ❑ New Pum ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well CasingSID WELL CONSTRUCTION Ia Drilling Method X Mud Rotary ❑ Air Rotary ElAuger LlCable Tool 11Push Point L-1OtherSANCIA Proposed Well Depth L ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel SizeHEA1-T4q jr 7Y ❑ ConductPr Casing in diameter / Conductor Casing Depth ft FAA A 4f, T Well Casing Diameter (V in Thickness/Gauge/ASTM SchedSDk Z I ❑ Steel k Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth (D(—ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water c(Bentonite(20%solids) ❑ Other Grout Placement Method A Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller u Pump Contractor ❑ Other ❑ Concrete Pedestal[I Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT 1 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 4 A VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-76Q7 SIGNED TITLE lJr '� DATE 1 C� ------------- DEPARTMENTUS O LYQ� Application Accepted By / ° Date Q� Area—1�= � Employee]D#—J,--/111T Grout Inspection By V Date —` /SPECIAL WeII Permit i- Pump Inspection By Date WAIVER Received Soil Boring Inspe tion By Date Const r c d Well D pth S i� �� ft C MMENTS P SC ved Chec A Date ^r Invo ce# W II ID# Codes Info B ash Remitted Service Re uest# f L43 P d I EHD43-06 6/11/2019 WELL/PUMP PERMIT