Laserfiche WebLink
r)r �. <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUINDAB ERMIT o www.sjg%v.org/ehd EXPIRES 1 EAR FROM DATE ISSUED <br /> JOB ADDRESS oe" r CITY/ZIP "4 W C V m <br /> r <br /> 2 D <br /> CROSS STREET ��^ APN a 3 qo 8o7J PARCEL SIZE ),30 LAND USE APPLICATION# A <br /> OWNER NAME OCA Y-1 Of A I C L I C PHONE V 1 bW1 <br /> OWNER ADDRESS / e `� Y ✓ CITY/STATEIZIP C 0 ✓ " 4Z <br /> CONTRACTOR Lq 6(✓ri F L• m Ln t IRHONEO�(/Q w—/ <br /> CONTRACTOR ADDRESS L4 r ` r A I S O01 <br /> SUBCONTRACTOR/CONSULTANT 1 '� PHONE 1 7 <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CIIT/7TY/S�TTATE/ZIP <br /> LICENSE _ C-57 V1 C-61 _ D-09 �thefy 1 NUR •MBE `e EXPIRATION DATE , <br /> 12, <br /> BILLING PARTY. OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELLS 7 <br /> PILING:❑General Mineral/Coliform Bacteria (4391) = Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/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 U Replacement Well U Well Alteration/Modification _j Other <br /> - Monitoring Well(s) #of wells 11 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 Pum c$Num Replacement ❑ Pump Repair C Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method _ Mud Rotary U Air Rotary Li Auger _ Cable Tool L Push Point _ Other <br /> Proposed Well Depth ft Excavation in diameter -I Open Bottom L Gravel Pack/Gravel Size n diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched J Steel U Plastic _ Stainless Steel U Other <br /> Grout Seal Depth ft n Neat Cement(94 lb bag/5-10 gal water) n Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) ❑ Other (� <br /> Grout Placement Method - Pumped n Free Fall n Other fl Retardant/Accelerator(name) j <br /> PEDESTAL Installed By - Driller ❑ Pump Contractor C Other <br /> _ Concrete Pedestal UDimensions:Width ft Length ft Thick in _ Christy Box U Stove Pipe <br /> PUMP Submersible- Turbine f1 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 c_- <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS S <br /> CURRENT AND ACTIVE WITH TN CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LA <br /> Fu <br /> III UM 48 H OPOV C 'rv;= dUl ED F0 INSP1E�CTIO�NS -PLEASE CALL (209�j 53-7697 <br /> SIGNED TITLE V / CSC/ (n CAA ! DATE ✓ <br /> I , <br /> q <br /> A N O <br /> pR A <br /> DEPARTMENT USE ONLY <br /> Application Accepted By 21 G_ Date 61,W2 0,90 Area S �i�t Employee ID# s <br /> Grout Inspection ByDate LJSPECIAL Well Permit <br /> Pump Inspection By tCQ1 eS& GQCOI`G t- NAL Date Q[Lo It, ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> q39? 050 $77 (P•1 20 PQ . <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />