WP0040995 - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMIT 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 t� ylx� �9n 'Ihnpl�.Pn � �/� �5o t Ln ADDRESS CITY/ZIP m m D CROSS STREET APN1 ,�I O! PARCEL SIZE I S 1 LAND USE APPLICATITI/ONN# �J c OWNER NAME 1� {t- PHONE oW-`�`�LQ~L q//y OWNER ADDRESS I l lDWA SJ I CITY/STATE/ZIP�Sk� � /�vWS CONTRACTOR 1 PHONE�� j/��/��J^VL V CONTRACTOR ADDRESS { CITY/STATE/ZIP f.�s (�T�'( J(� SUBCONTRACTOR/CONSULTANT i& PHONE SUBCONTRACTOR/CONSULTANT ADDRESS ITY/STATE/ZIP LICENSE 1-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE ' BILLING PARITY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane(4392) ❑ Arsenic(4393) INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WOR-C ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter D 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 lb 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 HP Pump Set ft Standing Water Level 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. MUM W0_LJA AD CE NOTICE REQUIRED FOkZ INSPE TIONS -PLEASE CALL (209) 9$3-76 7 SIGNED TITLE DATE T O lirv DEPARTMENT USE ONLY N�,gCTy�OpMENTUIV7'y Application Accepted By �L�J L Date 7 ,?od U Area 9 9 Employee ID# E/yT Grout Inspection By .( �" Date ❑ SPECIAL Well Permit Pump Inspection By �-t��ty..�i'� �uLt�. i.L Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE Sc Received Amount Permit/ Codes Info By Cash Remitted Date Servicp Re uest# Invoice# Well ID# y3F I vso 7 E H D 43-06 6/11/2019 WELL/PUMP PERMIT