WP0040462 - Laserfiche WebLink

Home Browse Search

4 WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 NON-REFUNDABLE PERMIT Q ww1w.s ov.or /ehd EXPIRES 1 /YEAR FROM DATE ISSUED LD JOB ADDRESS ,( 3141 Je�dr�Ir �—N' CITY/ZIP�sca IelA Com_ 7S L40 m CROSS STREET I�{w� �Zd _APN 2,29_IS O [�O PARCEL SIZE I• LAND USE APPLICATION# rn __ _ o OWNER NAME- R Z ukrA Q T 7 ) p U) _l,_1�IA.� ` - - PHONE 1pUZ� V7 p��yy---- to OWNER ADDRESS 14>3 3` _ S e t Y,'e r CITY/STATE/ZIP SC b CLl_ `5 J L-0 �- CONTRACTOR PHONE�2 t q2-1011 CONTRACTOR ADDRESS 6 L� A l h C r S • CITY/STATE/ZIP M Dd—,-s o SUBCONTRACTOR/CONSULTANT PHONE SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP i D-09 ❑ Other NUMBER r �7�' EXPIRATION DATE LICENSE )(C-57 CI C-61 _1Q�cGa�a�l1 q-3d ' 2,-7,- BILLING '�/ BILLING PARTY: I OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WE L SAMPLING:' i General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) INTENDED USE Domestic/Private U Irrigation/Agricultural U Industrial P Water Quality Monitoring is Soil Sarnpling/Characterizaat M i] Public Water System_ If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK New Well I 1 Replacement Well 0 Well Alteration/Modification n Other_ _ 1d Al #of borings #of bo in �O ❑ Monitoring Wells) #of wells 1.1 Soil Boring(s) _ s ❑ Geotechnical cw•- 0 Out-Of-Service Well I7 Out-Of-Service Well Renewal ❑ Cross-Connection Repair --' V�OAQY/N ?0 ❑ New Pump 0 Pump Replacement D Pump Repair U Raise Well Casing 1 RO/y COu WELL CONSTRUCTION p .gRrM�N� Drilling Method)(Mud Rotary ,❑ Air Rotary 0 Auger ❑ Cable Tool n Push Point ❑ Other Proposed Well Depth 3QO _ft Excavation )2—/1 in diameter 1_I Open Bottom Gravel Pack/Gravel Size_in diameter II Conductor Casing in diameter / Conductor Casing Depth ft Weil Casing Diameter b in Thickness/Gauge/ASTM Sched Z-�d I-i Steel X Plastic i i Stainless Steel CI Other Grout Seal Depth 204 ft a Neal Cement(94 Ib bagl5-10 gal water) I Sand Cement sack mix17 gal water (Bentonite(20%solids) 0 Other Grout Placement Method OKPumped ❑ kree Fall -I Other i Retardant/Accelerator(name) PEDESTAL Installed By U Driller 4PUrnp Contractor ❑ Other 0 Concrete Pedestal DDimensions:Width it Length ft Thick in Ll Christy Box I I Stove Pipe (PUMP ❑ Submersible Turbine U Other HP Pump Setit 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. MINIV 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 953-7697f SIGNED TITLE C-11� DATE 1 ` NPA. — s -a r Y %A 110, DEPARTMENT USE ONLY Application Accepted ByAA Date 1=1 Area // Employee ID#��, Grout Inspection By Date SPECIAL Well Permit Purnp Inspection By Date WAIVER Received Soil Boring Inspection By Date Constructs Well Deth�� ft COMMENTS Q ::t.L- FQ�1A1A6 1AI PE Se Received She Amount Permit/ Codes Info B ash_ emitted Date Service Request# Invoice# Well ID# —2—q _ '� r - ✓ l- 2 -- 38. E Ips r z� _ ODS{ EHD 43-06 6/11/2019 WELL/PUMP PERMIT