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 /> JOB ADDRESS l 4 1jr5lo.,, frog y �' <br /> RO CITY/ZIP �IoLLG-�O�v m <br /> D <br /> CROSS STREET I L ;I 671--0 E APN I//—ZAD^r7 l�0-000 PARCEL SIZE 7.&etc LAND USE APPLICATION# A <br /> OWNER NAME SYoLJr 7191-1 0/-)r=r6+ <br /> SG1 }��o01. 1/iSrlrl,-,l PHONE Zo41.7-70Y)-` � 41.7-70Y)- (n <br /> OWNER ADDRESS tO4CITY/STATE/ZIP <br /> CONTRACTOR V 49 WIA/C PHONE C_�Z_�0 77090 <br /> 7�00 <br /> CONTRACTOR ADDRESS I1 37 �tgtk(W-1*�/ R� CITY/STATE/ZIP ':e+jfCA p6 z- <br /> SUBCONTRACT O n� PHONEI /1J <br /> SUBCONTRACTO LTANTADDRFSS 3®IU /"V okll.�,14, 4�,VD 75 <br /> CITY/STATE/ZIP E'&&T S'ICd4-IP40 CA' /S6 Qj <br /> LICENSE ( C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER72,079) EXPIRATION DATE_J ZDlm <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACT ONSLT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)r 1 Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring Iksoil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings Geotechnical 6 of borings <br /> ❑ Out-Of-Service Well 11 Out-Of-Service Well Renewal EI 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 Depths— Sy -4 ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> 11 Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel LI Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depthft y"Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method 1`1 Pumped YFree Fall srOther 7tE-hce /G N"(4tardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal[]Dimensions:Width ft Length ft Thick in LI Christy Box ❑ Stove Pipe <br /> rPump ❑ 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 /> MIN104M 48 HOUADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209) 953-7697 <br /> SIGNED TITLE SrgfC� �tocO G i1�c DATE L�Z��Z� <br /> J <br /> R <br /> Op <br /> DEPARTMENT U N L Y <br /> Application Accepted By Date ZOZD Area /Yockkmployee ID# r a i <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By iL44i1el Date_.3 0 Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received hec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B a h Remitted Service Re uest# <br /> l5 z 6.00 2 Ztc <br /> EHD 43-06 6/1112019 WELL/PUMP PERMIT <br />