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 IWWW.S oV.Or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CITyIZIP 1 <br /> Z '7 � D <br /> CROSS STREETAPN :>< �a I PARCEL$fZE t 3 / LAND USE APPLICATION# o <br /> OWNER NAME P ONE <br /> OWNER ADDRESS CITY/STATE/ZIP <br /> CONTRACTOR PHONR:, ����(l..ln�C�t.yJ�y- <br /> CONTRACTOR ADDRESS / CITYISTATEMP� 64 7 I.tJC� <br /> SUBCONTRACTOR/CONSULTANT A PHONE <br /> $uacDNTRAcN:RICONSUL7ANT ADDRESS I / q p <br /> LICENSE 57 C-61 D-09 Other NUMBER4M EXPIRATION DATE <br /> BILLING PA OWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:'i General Mineral/Coliform Bacteria(4391). Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Ybomestic/Private 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 Well Alteration/Modification Other <br /> MonitoringWell(s) of wells SoilBonng(s) #ofbodngs Geotechnical #ofbarings <br /> Out-Of-Service ell Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement _i 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 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 i Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mixl7 gal water <br /> Bentonite(20eh solids) Other <br /> Grout Placement Method Pumped i Free Fall , Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller i'Pump Contractor i Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine .Other HP Pump Set it Standing Water Level It <br /> I HEREBY CE FY THAT 1 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 CO�NSTIONAWS. <br /> MINIR A OT10E REQUIRED FOR IN,�pE'C,TIyOJ/NJS'-PLEASE CALL(209)9 3-7 97 <br /> SIGNS TTrLE �i`7i/!�` DATE <br /> NO <br /> E ENT <br /> VEP <br /> 0 5 2020 <br /> UIN <br /> R NMENTgL 7Y <br /> Lt jyyj PARTMENT <br /> J� EPARTMENT US ONLY <br /> Application Accepted By Date aArea-3 6y�t Employee ID# �� <br /> Grout Inspection By Date I SPECIAL Well Permit <br /> Pump Inspection By 41WA-.5la (-Wv DateI WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth it <br /> COMMENTS <br /> PE SC Received Check#I Amount Date Permit/ Involca# Well ID# <br /> codes Into B ash Remitted Service Request* <br /> -$ <br /> FI-104.3-06 8111/7018 WELL 1PQMP PERMIT <br />