Laserfiche WebLink
0101 <br /> WELLIPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT I/] .S Ov.Or /ehd EPXPI(/R^)ES 1 /Y/E�AR FROM DATE ISSUED <br /> JOB ADDRESS V' CITY/ZIP �"' `� V m <br /> Rct. o70$ISbOL' <br /> CROSS STREET -'ecirl e APN I PARCEL SIZE + LAND ULU APPLICATION# A <br /> OWNER NAME 1 1 ""�I v`a� YHON 1 6 ' r v `� y <br /> J <br /> OWNER ADDRESS Is U r � � CITYISTA I ! ✓ ,J <br /> e V t �� J 1 PHONE ✓�v d <br /> V (� <br /> CONTRACTOR ,o �j� V , <br /> CONTRACTOR ADDRESS "" / I Y STATE P �� Cel 9 0 <br /> SUBCONTRACTOR/CONSULTANT �PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS �' L CITY/STATE/ZIP ' V 1 2 () <br /> LICENSE _ C-57 XI C-61 _ D-09 U Other NUMBER (a(0 G U EXPIRATION DATE <br /> BILLING PARTY: OWNER CONTRACTOR -1 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELLS PILING: ❑ General Mineral/Coliform Bacteria (4391) - Dibromochloropropane(4392)❑ Arsenic(4393) <br /> INTENDED USE _ omestic/Private U 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 L Replacement Wel; a Well Alteration/Modification j Other <br /> - Monitoring Well(s) #of wells n Soil Boring(s) #of borings - Geotechnical #of borings <br /> Out-Of-Service Well u Out-Of-Service Well Renewal u Cross-Connection Repair <br /> - New Pump ump Replacement ❑ Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION (� <br /> Drilling Method _ Mud Rotary L Air Rotary u Auger _ Cable Tool L Push Point Other <br /> Proposed Well Depth ft Excavation in diameter -j Open Bottom L Gravel Pack/Gravel Size in diameter <br /> ConductorCasing in diameter . / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched J Steel u Plastic _ Stainless Steel a Other <br /> Grout Seal Depth ft n Neat Cement(94 Ib bag/5-10 gal water) Fl Sand Cement sack mix/7 gal water <br /> - Bentonite(20%solids) - Other <br /> Grout Placement Method - Pumped n Free Fall n Other F-I Retardant/Accelerator(name) <br /> PEDESTAL Installed By - Driller ❑ Pump Contractor C Other (`\� <br /> _ Concrete Pedestal uDimensions:Width ft Length ft Thick in _ Christy Box a Stove Pip v 1 <br /> H - W �V <br /> PUMP Submersible- Turbine ❑ Other HP Pump Set ft Standing Water Level ft c1`! <br /> _ I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY DIN CES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACT V IT THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPEN A ON AWS. <br /> MINIM 116H URA NCE NOTICE REQUIRED FORA SSPECT{I� /� <br /> ON�S -/P�LE/ASE CALL 209{(]]]�Cj] ' -7697 <br /> SIGNED TITLE `>_ " V11(t / / f.l/t,y 1 DATE <br /> 7 <br /> D <br /> s <br /> M /N <br /> i N N Ty <br /> AIRTIM�T <br /> L. <br /> DEPARTMENT USE ONLY <br /> r <br /> Application Accepted By L Date S /3bozo Area 9�1 Employee ID# :5k <br /> Grout Inspection By " Date C SPECIAL Well Permit <br /> � <br /> Pump Inspection By 4lk,-yCSLo �G x �q� Date (pjII9j2oT Zy C WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received heck#/) Amount Permit/ <br /> Codes Info B Cas Remitted Date Service Re est# Invoice# Well ID# <br /> 381 05c7 a i3 yU <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />