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.S OV.Or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Cn <br /> JOB ADDRESS 17900 w• 8� T 14^^, ya sLrp� CmrrzlP )(4c} �1 . C.�} 53 S m <br /> CROSS STREET L a 1 1 LCe� APN PARCEL SIZE LAND USE APPLICATION# p <br /> OWNER NAME f1 p11 K l `` T=�L Q \ -Z �T-/P^HONE W� \/�� Dq�5 p� 2�� y <br /> OWNER ADDRESS 17'1 P w' ��5L / li&L, / Ind ` CITYISTATEMP 1I An-:j CA 15-1 t i <br /> CONTRACTOR A�-4,41A ^� 0 `G,EO ^rIr0ArA£/�T� ��'`•• PHONE'?-C' \ - *91-1 00 "e <br /> CONTRACTOR ADDRESS o 1-7 .5 I�l A,V,/ AO A CRY/STATE/LP S-i o cK 1 Or-, C i"r �szl f <br /> SUBCONTRACTORICONSULTANT S A 7A;— A-S A-5 4,Q PHONE if <br /> I , <br /> SUBCONTRACTOR/CONSULTANT ADDRESS it 't C[TYISTATEMP I t I I I t <br /> LICENSE '7E,C-57 C-61 D-09 Other NUMBER 0 P Z L I EXPIRATION DATE <br /> BILLING PARTY: _OWNER XE ONTRACTOR _ SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPUNG: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domesfic/Private Irrigation/Agricultural ' Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Neme Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Bohng(s) pot borings Geotechnical 8 of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> =New Pum Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary -t<A_ugar Cable Tool Push Point Other N �� <br /> Proposed Well Depth NI A it Excavation 1,J /k in diameter .Open Bottom i Gravel Pack/Gravel Size NIA in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth Z 5 it Meat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method umped Free Fall ]Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor' Other <br /> _ Concrete Pedestal _Dimensions:Width it Length it Thick in _ Christy Box _ Stove Pipe <br /> PUMP Submersible Turbine Other HP Pump Set it 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 WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 48 H R A,/AN NOTICE REQUIRED FOR INSPECTIONS-/P�LEAS(E^CAALL(209)953-7697 C <br /> SIGNED / TITLE I�`C�- i `'VA�r DATE )z—( <br /> TI 11 111111 11111 11111 <br /> MFNt <br /> VFO <br /> AY, <br /> ?419 <br /> co <br /> �Hn' <br /> TMFNT <br /> _ r DEPARTMENT U lE 0 LY //� <br /> Application Accepted By Date Area G Employee I. K r/ <br /> Grout Inspection By r Date I 1 PECIAL Well Permit <br /> Pump Inspection By A ate/ 1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Chec Amount Date Permw Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Re uest# <br /> C' <br /> EH043-M 6111=19 WELL'PUMP PERMIT <br /> ` 7 <br />