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 PER��M//11IT ),,www.s ov.or /ehd j/EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> 11 �a J * CITY/ZIP N0� C� ✓ �p14 m <br /> 1 D <br /> CROSS STREET C�Y 01 TOr a t APN a0,67()30 PARCEL SIZE S I LAND USE APPLICATION# A <br /> Y�G1 V15 G 5� i t , 41-0Ll 57,7 <br /> OWNER NAME }� <br /> OWNER ADDRESS ' G /1/0 CITY/STATE/ IP/ �) Q <br /> CONTRACTOR �J JJ�� _���/c ] .AE urI,1 c ���/ /,/ <br /> CONTRACTOR ADDRESS �V�hh/ / 1/I it�/1 K�IA CITY/STATE 1 V `f� �� ...+ <br /> SUBCONTRACTOR/CONSULTANT 'Y {-i//��� PHONE I Y <br /> /11 <br /> P1 qq <br /> SUBCONTRACTOR/CONSULTANT ADDRESS ( Y CITY/STATE/ZIP <br /> It I <br /> z C <br /> LICENSE _ C-57 VC-61 _ D-09 U Other NUMBER` "' v EXPIRATION DATE ✓ a a\ <br /> BILLING PARTY: OWNER fl CONTRACTOR 7 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria(4391) - Dibromochloropropane (4392)❑ Arsenic(4393) <br /> o <br /> INTENDED USE Domestic/Private LI Irrigation/Agricultural _ Industrial _ Water Quality Monitoring _ Soil 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 I_l Well Alteration/Modification J Other ___ IIV7' <br /> - Monitoring Well1­1 #of borings s) #of wells Soil Boring(s) - Geotechnical v <br /> _ Out-Of-Service.Well _1 Out-Of-Service Well Renewal a Cross-Connection Repair ED <br /> - New Pump )(Pump Replacement ❑ Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION SAN JOq ?Q <br /> Drilling Method _ Mud Rotary U Air Rotary Li Auger _ Cable Tool L Push Point _ Other FF^X,.� �u <br /> Proposed Well Depth ft Excavation in diameter J Open Bottom L Gravel Pack/ f29*31 iameter <br /> - Conductor Casing in diameter / Conductor Casing Depth ft TMENT <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched J Steel u Plastic _ Stainless Steel Li Other <br /> Grout Seal Depth ft rl Neat Cement(94 lb bag/5-10 gal wafer) n Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) :1 Other <br /> Grout Placement Method - Pumped Fl Free Fall Other n Retardant I Accelerator(name) <br /> PEDESTAL Installed By - Driller ❑ Pump Contractor C Other <br /> _ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in _ Christy Box U Stove Pipe <br /> PUMP Submersible- Turbine n Other HP C 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 /> MINI 4 CTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209) 953-7697 <br /> SIGNED OUR A ANE NOTLE I ! 1 0 DATE ` r <br /> 77 <br /> LA PIC e <br /> �. <br /> 2021 <br /> _,4 <br /> E IR NM N A E L H <br /> ER IIT S R I E <br /> f/ <br /> DEPAR MENTUSfEONLY <br /> Application Accepted By ` Date o7 ,?O.70 Area y <br /> Employee ID# <br /> Final Inspection By j ' cn `2 Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil to Depth of 3 Ft: Pit/Sump Soil Character: <br /> COMMENTS <br /> PESC Received Check Amount Permit/ <br /> Code INFO B Cash Remitted Date Service Re uest# Invoice# Permit ID# <br /> y381 050 77 12� WPB p�13 <br /> 42-01 ONSITE WASTEWATER TRTMNT SYSTEM PERMIT <br /> 4/14/18 <br />