Laserfiche WebLink
WELL/PUMP PERMIT <br /> �- SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE•STOCKTON CA 95208-6232(209)468.3420 <br /> • <br /> NON-REFUNDABLE PERMIT pwww.sjgov.org/ehd EXPIRES 1 YEAR <br /> 'FROM DATE ISSUED <br /> JOB ADDRESS a// S aG- CU) I7\ r/ CTYZPpCcir17iC >u��C <br /> m <br /> CROSS STREETU-J SnC(.t I1(Y" 47APN oo 5 - 376,27PARCELSZE J ty7 <br /> I LAND USE APPLICATION N A <br /> OWNER NAME PHONE u <br /> —T <br /> OWNER ADDRESS `' f� CRY/STATE01' 7 —I Q <br /> CONTRACTOR V:�IO1 7 �](J 1 t I I r 9 PHONE J�I,I Y [//� I <br /> CONTRACTOR ADDRESS 1 'O r7 Ct���9 CITY/STATE/LP 6Oj �I C'A C1 JV'3 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY1STATE17jP '] <br /> LICENSE XC-57 C-61 D-09 Other NUMBER -11 3 — <br /> S_7 EXPIRATION DATE / —3 <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)::Dibromochloropropane(4392) Arsenic(4393) � .CC/�G <br /> INTENDED USE 7(DomesticlPnvale Imgation/Agnalltural Industrial I I Water Quality Mondonng - Soil Sampling/Cheractenzahon C ED <br /> -.Public Water System RAR <br /> I(dillerent from 0vmer. Water System Nem. Contact Name a Phone Number <br /> TYPE OF WORK )L New Well Replacement Well Well AReration/Modificaton Other JOAQU <br /> dRTM <br /> 2 <br /> 020 <br /> Monitoring Wells) N of wells Soil Bonng(s) aofbol"se Geotechnical aofbongs --w/�a/VcOOUt-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair H <br /> New Pum D Pu Replacement Pum Repair Raise Well Casing LT PET <br /> WELL CONSTRUCTION 7- <br /> Drilling <br /> Drilling Method K Mud Rotary O Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth 2A 5 ft Excavation��in diameter .Open Bottom 7( <br /> Gravel Pack/Gravel Size )�—in diameter <br /> Conductfl <br /> Conductor Casing in diameter ! Conductor Casing Depth <br /> ( <br /> Well Casing Diameter-,i--in Thickness/Gauge/ASTM Schad d,kL Steel Plastic Stainless Steel Other <br /> Grout Seal Depth C o ft Neat Cement(941b bag/5-10gal water) 7(Sand Cement 110•.�7 sack mix/7 gal water <br /> Bentonde(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Instilled By rider Pump Contractor Other <br /> Concrete Pbdestal Dimensions:Width it Length It Thick in Christy Bax Stove Pipe <br /> PUMP ).Submersible Turbine Other HP Pump Set_j45___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 /> MINIMU 48 OU�R�AwDVVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)7953-769 <br /> `J <br /> SIGNED n''W`s' ` TITLE •1 e- Y rt+ DATE <br /> L <br /> IL <br /> C <br /> /r / DEPARTMENT USE N L Y <br /> Application Accepted By _`, L/ Date S Z5J ZJ L Q Area �C Employee IDN <c3et]IM <br /> Grout Inspection By Date i 2-{� PECIAL Well Pernntt <br /> Pump Inspection By -��[ ��- \,: r'` ilw,a Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth h <br /> COMMENTS 4,eQ r <br /> PE SC Recely CheeklN Amount Penn Invoice N Well IDN <br /> Palo-/Codes Info Remhted Service Re uesto <br /> #Hs- <br /> -17R <br /> - <br /> -1 R <br /> L i$v ZO U <br /> q3 x� ) ' - <br /> EHD 4306 611111019 WELL/PUMP PERMIT <br />