Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE-PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> CITY/ZIP A <br /> LA m <br /> D <br /> CROSS STREET APN �� PARCEL SIZE LAND USE APPLICATT34-c��t6 <br /> m <br /> OWNERNAMEPHONE U)I <br /> OWNER ADDRESS CITY/STATE/ZIP&Wkft. 61491 <br /> CONTRACTOR <br /> PHONE <br /> CONTRACTOR ADDRESS -� <br /> OCD CITY/STATE/ZIP �l <br /> SUBCONTRACTOR/CONSULTANT PHO <br /> SUBCONTRK-57 <br /> CTOR/CONSULTANT ADDRESS N 4��& <br /> /STATE/ZIP <br /> XX*-�- <br /> LICENSE ❑ C-61 CI D-09 ❑ Other NUMBER EXPIRATION DATE 5 <br /> BILLING PARTY: D OWNER LI CONTRACTOR D SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391) ❑ Dibromochloropropane(4392)❑ Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural D Industrial ❑ Water Quality Monitoring D 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 Well(s) #of wells D Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well D Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Too[ D Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter D Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> D Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic D Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fail ❑ Other D Retardant/Accelerator(name) <br /> 1��7 <br /> Installed By ❑ Driller ❑ Pump Contractor ❑ 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 /> I HEREBY CEffTIFY 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 /> WORKER MPENSATION LAWS. <br /> UM H U DV NCE NOTI E REQUIRED FOR SP NS -PLEASE CALL(209) 6 <br /> SIGNE TITLE DATE <br /> fl I <br /> E <br /> I All <br /> Mj J A UI I C O N <br /> R <br /> E P Alf T M E N T UqS E N L Y <br /> C <br /> Application Accepted By Date Area Employee ID# <br /> Grout Inspection By Date / CI PECIAL Well Permit <br /> Pump Inspection By F t`fNr\!•`�t c 04Ar kJ1, Date l � �7.V'LV Cl WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Permit/ <br /> Codes Info By_ Cash mitted Date Service Request# Invoice# Well ID# <br /> 2- <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />