Laserfiche WebLink
WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCKTON CA 95205 -6232 (209) 468-3420 <br />PMN-MtFUNUABLE PERMIT <br />W1NW.5 Ov.Or ier10 tAVIKt.J 7 TEAR FKOM UAIL ISSUtU <br />JOB ADDRESS ^l ' " C� I <br />`` ,, 1 `,. `, <br />N I s e � t' � % C� <br />� � <br />CITY/ZIP <br />Code. <br />G) <br />C■ <br />- I <br />O' <br />CROSS STREET \� 1� 1 'f} <br />V APN G 19 ' <br />I U C: <br />PARCEL SIZE I LAND USE APPLICknON <br /># I <br />I <br />OWNER NAME <br />\/ r <br />J <br />PHONE <br />OWNER ADDRESS )I <br />�I 0C 1 �� S�lt <br />�- <br />! <br />CITYISTATE/LP_ 4. It MC Y/1 '[-t�' <br />C —7 <br />� J�� / <br />\ <br />CONTRACTOR �l �1J` Ly <br />Iy7� CJ1 1 I/1'11 �) <br />PHONE �k'^I <br />-7 Q <br />/ 1z% <br />CONTRACTOR ADORERS Y G <br />1 / �' /� �t <br />CrTY/STATE/L/ <br />P G", I I l <br />I T 1 <br />SUBCONTRACTOR/CONSULTANT <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE -�4\C-57 ❑ C-61 7 D-09 0 Other <br />BILLING PARTY: D OWNER <br />❑ CONTRACTOR <br />CrTYISTATE/LP_ <br />NUMBER �G L `5 <br />is SUBCONTRACTOR/CONSULTANT <br />EXPIRATION DATE 7 -3 1 - ;) l:' <br />DOMESTIC WELL SAMPLING: -- General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) _. Arsenic (4393) <br />INTENDED Use-7Womestic/Pnvate 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 />Monitoring Wells) If of wells Soil Boring(s) 0 of bOnngs Geotechnical o1 bonngs <br />Out -Or -Service Well Out -Or -Service Well Renewal Cross -Connection Repair <br />Drilling Method Mud Rotary _. Air Rotary _ Auger Cable Tool Push Point Other <br />Proposed Well Depth 3G�5 ft Excavation ) in diameter 0 Open Bottom �11 Gravel Pack/Gravel Size�� in diameter <br />'-Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in 7hickness/Gauge/ASTM Schad �(;_ 0 Steel j( Plastic _Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 1b bag/5-10 gat water) 7/. Sand Cement I C n 3 sack mi,xT7 gal water <br />',11. Bentonite (20% solids) - Other <br />Grout Placement Method .Pumped Free Fall _ Other -1 Retardant / Accelerator (name) <br />PEDesraL Installed By �f-Dnller Pump Contractor F Other <br />Concrete Pedestal "-Dimensions. Width__._ ft length ft Thick in Christy Box - Stove Pipe <br />PUMP Submersible'. Turbine -- Other HP _-�_ Pump Set - ft Standing Water Level ft <br />1 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 ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED % •f1L4/iee^ TITLE �T(�lCf i' l C , <ACn DATE <br />SA ENG RO <br />NSp�CH <br />U" . <br />Application Accepted By �`"� Date t: _O to X JJ30 Area 7 f -I Employee ID# <br />Grout Inspection By Date Y �ie% __ SPECIAL Well Permit <br />Pump Inspection By C..ti Date f WAIVER Received <br />Soil Boring Inspection By Date Constructed Weil Depth 11 <br />COMMENTS <br />PE <br />SC Received <br />Check#/ <br />Amount <br />Date <br />Permit/ Invoice # Well ID# <br />Code. <br />Info B <br />C■ <br />Remitted <br />ervice RequeAt# <br />Zel <br />3c' <br />; lys <br />LU f r <br />I T 1 <br />EHD 43-W 6/11/2019 <br />WELL /PUMP PERMIT <br />