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 /> ` P V1 <br /> JOB ADDRESS /� -JG��� �`�L��C �`/� Clnr/ZIP Cl`.-�p�L'1 m <br /> 2 � /,,�/ u v�� D <br /> CROSS STREET���� �-�V APN ✓�1�" 1 ✓� PARCEL SIZE IN r LAND USE APPLICATION# A <br /> m <br /> En <br /> OWNER NAME PHONE �? <br /> OWNER ADDRESS ���gy �,.. L CITY/STATE/ZIP �1 <br /> CONTRACTOR \�\IItV I�1-`�` -If SO`^_/Tt_ fIeC0r\ �OnSln\T��S - AC PHONE Zr( _ ab_7 rl JJ01 <br /> CONTRACTOR ADDRESS -1� ./V�I�uSy�T''T`a\ tV CITY/STATE/ZIP Aa b� A '5( 1' io <br /> SUBCONTRACTOR/CONSULTANT `�l IA- PHONE\f \y r l <br /> SUBCONTRACTOR/CONSULTANT ADDRESS `r CITY/STATE/ZIP <br /> LICENSE `�,C-57 C-61 D-09 Other NUMBER v�'"" L EXPIRATION DATE - <br /> BILLING PARTY: OWNER _ CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)J Dibromochloropropane(4392)- Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial C 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 U Well Alteration/Modification I Other <br /> Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings Geotechnical #of borings <br /> Out-Of-Service Well F1 Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement LI Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger. ❑ Cable Tool Push Point Other <br /> Proposed Well Depth i& �50 ft Excavation " in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched 1 Steel i Plastic I Stainless Steel � Other <br /> Grout Seal Depth ft ,Neat Cement(94 Ib bag/5-10 gal water) i Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped 6 Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By � Driller ❑ Pump Contractor Other <br /> Concrete Pedestal❑Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine D 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 /> MINI UM 8 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)953-7697 <br /> SIGNED TITLE C�� rVl/j �1Z t' ( DATE V D O <br /> 1 <br /> r <br /> ISAN <br /> q=T] F I <br /> � � Q / <br /> c <br /> EPARTMENT USE ONLY <br /> Application Accepted By e Date S Area L,,4 i Employee ID# LA <br /> Grout Inspection By Date — SPECIAL Well Permit <br /> Pump Inspection By < Date 71 WAIVER Received <br /> Soil Boring Inspection By I VdA, Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Bv Remitted I Service Re uest# <br /> 1 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />