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 ADDRESSCITYIZIP b✓I �t� �-/ / _ my <br /> , Y—(.3L- 1 � -f� <br /> CROSS STREET�'r�L•>b.,Q r,.a�. pZAPN "�PARCEL SIZE V Y ^'LAND USE <br /> APPLICATION#'` 0 <br /> OWNER NAME G7tT U;�J r['l2.bL:.—C PPJHION'E I-f ">•/J1 •'-�YJ[J J N <br /> OWNER ADDRESSC+Tj C7 1 t''7� CITY/STATE/ZIY <br /> CONTRACTOR ,F/•� �X�t�(Is�j \t*AL F PHONE 1f�j G'`� -•�`�Z'C� <br /> CONTRACTOR ADDRESS S2! 1t1 1 I 'kms LC��D`�-J�� �-�"� CITY/STATE/ZIP�� G� ���fT_ <br /> SUBCONTRACTOR/CONSULTANT.. 5 PHONE <br /> SUBCONTRACT'Y-\C-57 <br /> OR/CONSULTANT ADDRESS CITY/STATE/ZIP �7 <br /> LICENSE �[C-57 -'.C-61 D-09 -1 Other NUMBER_�* ExPIRATION DATE <br /> BILLING PARTY: ❑OWNER 0 CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING;I I General Mineral/Coliform Bacteria(4391)0 Dibromochloropropane(4392)E,,Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial D Water Quality Monitoring Soil Sampling/Characterization <br /> If different from Owner: Water System Name Contact N o or Phone Number <br /> TYPE OF WORK New Well r-.Replacement Well I Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells n Soil Boring(s) #of rings eo ec ni I #of borings <br /> Out-Of-Service Well L Out-Of-Service Well Renewal LI Cross-Connection Repair /1 <br /> New PUMP Pump Replacement L'Pump Repair "i Raise Well Casing P!i <br /> WELL CONSTRUCTION (f�P_\\� Cpl 's` EF M,ENr <br /> Drilling Method Mud Rotary Air Rotary }Auger Cable Tool Push Point +(Other /`► <br /> Proposed Well Depth � _) ft Excavation in diameter i Open Bottom Gravel Pack/Gravel Size in di�wAr <br /> Conductor Casing in diameter / Conductor Casing Depth fl //���.l,1 � �O <br /> Well Casing Diameter .in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other ?O <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-f0 gal water) _Sand Cement sac <br /> Bentonite(20%solids) II Other /N COUNTY <br /> Grout Placement Metho Pumped 1 Free Fall Other Retardant/Accelerator(name) H EN TA L <br /> PEDESTAL Installed By Driller I_ Pump Contractor Other ART MENT <br /> Concrete Pedestal I;Dlmenslons:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br /> 1 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 WIT THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION WS. <br /> nINIMUM 4 FiOt ANCE NOTICE REQUIRED FOR INSPECTION';-PI EASE CALL(209)9p3-7697 <br /> SIGNED TITLE \ lLj��'-7l � DATE <br /> DEPARTMENT USE ONLY_1"C-'�T �— <br /> Application Accepted By ' Date r./ oz- ZJL O Area = (� rr Employee ID#� <br /> Grout Inspection By Date El SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date tConstrurt-�+'"/^II Depth <br /> /1?11 M <br /> COMMENTS ' Q S lL!1 r 3 ry _l+T 7✓ As I 1p, r rte! <br /> --- <br /> PE Sc Received Ch Amount Date Permit! Invoice# Well ID# <br /> Codes Info as Remitted S rvice Rv uest# <br /> °ISiI �Fr „iSJ <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />