Laserfiche WebLink
rJ AZv s a k3 <br /> 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 I`�� /�'`t�( 1�._:C,` CrrY21P '\ Y�`L-`', `l S ?i-'`I -- m <br /> CROSS STREET o r.v 1„�., P�r����' _APN '� 1 .i- `-l� �'` PARCEL SIZE ' ( LAND USE APPLICATION# A <br /> m <br /> to <br /> OWNER NAME PHONE �? <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR ?, f C Ancr.-Su17-1 PHONE (Zy`i1 <br /> CONTRACTOR ADDRESS 110 Z �r r1.:',E�""( l.Vc�-� CITY/STATE/ZIP ji,:c�, C A `TS�-�l O <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE '/ C-57 C-61 D-09 Other NUMBER C.C. 'i�1, EXPIRATION DATE <br /> BILLING PARTY: OWNER }'CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: -General Mineral/Coliform Bacteria(4391)a Dibromochloropropane(4392)_ Arsenic(4393) <br /> INTENDED USE Domestic/Private ' Irrigation/Agricultural Industrial 1 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 -_i Replacement Well ❑ Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings y Geotechnical J #of borings <br /> Out-Of-Service Well ❑ Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement ❑ 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 1 t -S o 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 Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft l Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) Other �. c <br /> Grout Placement Method y Pumped +fl 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 1 1 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 /> MINIMUM 48 HOUR ANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)953-7697 <br /> SIGNED TITLE DATE 2`1 2.c2C <br /> Q <br /> 1PA <br /> CAJA—D <br /> J <br /> U <br /> D p <br /> / ,-DEPARTMENT E ONLY <br /> Application Accepted By V v Cvl Date ,/ �r Area J _ Employee ID# <br /> Grout Inspection By Fj U Date ❑ SPECIAL Well Permit <br /> Pump Inspection By _ Date p WAIVER Received <br /> Soil Boring Inspection By Date O Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#! Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Bv Remitted Se ice Request# <br /> 1. (� <_ 7 �' Gv 1' <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />