WP0040928 - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMITG �" SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS CITY/ZIP �J / � � m a CROSS STREET APN U�/e ��` �PARCEL SIZE ,7 LAND USE APPLICATION# Cn �s^7/ OWNER NAME °� PHONE /`!5 SD 03 p -(J 71— m OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR �/ OD//!// �IaG PHONE ��, /G�3 t � CONTRACTOR ADDRESS Z I C70 W l&c( X 12.e) CITY/STATE/ZIP_ `c5r,9A/ SUBCONTRACTOR/CONSULTANT �� PHONE SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIPLICENSE WC-57 OC-61 11D-09 ❑ Other NUMBER V Q)V EXPIRATION DATE J �;_F�4 BILLING PARTY: ❑OWNER 01ZONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings 0 Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump ArumpReplacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary 0 Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP Submersible❑ Turbine ❑ Other HIP�_ Pump Set Algl — ft Standing Water Level S — ft I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINM4 =VANCE NOTICE REQUIRED F�NSPECTIONS -PLEASE CALL (209) 953 697 SIGNEDCTITLE " DATE Z _ I 7L lkv I Id ENVIRO UNTy J DEPARTMENT USE ONLY HEALTHpNMENTAL Ift Application Accepted By � 1,L Date o1� aVa Ep Area �� Employee ID# P ENT Grout Inspection By ," Date -^� [I SPECIAL Well Permit Pump Inspection Bytra✓•c S�o CQQvt; Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received heck# Amount Date Permit/ Invoice# Well ID# Codes Info B Remitted Service Re est# 43$ os o115 r7-7 (0 EHD 43-06 6/11/2019 WELL/PUMP PERMIT