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.s ov.or /ehd _ EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS V ` ,• l D CITY/ZIP a✓ m <br /> I '1f D <br /> CROSS STREET I' 'yU�' �� APNN� L9 / J I 1 v O PARCEL SIZE _LAND USEAPJPLICATION�#? z /, <br /> e/ I ! 1 1 -s til PHONE " 3^ O Z5 J a <br /> OWNER NAME l/ - <br /> CA <br /> OWNER ADDRESS 2 ���V I:/ _ CITY/ST E/ZIP <br /> CONTRACTOR �� PHONE ')_0I,� f C �J c <br /> CONTRACTOR ADDRESS J U 01�" ` CITY/STATE/ <br /> �n <br /> N 1W l� <br /> SUBCONTRACTOR/CONSULTANT PHONE I <br /> A -A <br /> IV <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP 1 <br /> ' l n'n ' b <br /> LICENSE _ C-57 V� C-61 _ D-09 Other �� NUMBER (0(P EXPIRATION DATE1211-2U� <br /> BILLING PARTY: OWNER CONTRACTOR -1 SUBCONTRACTOR/CONSULTANT G <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) = Dibromochloropropane(4392)D Arsenic(4393) <br /> INTENDED USE Domestic/Private IrrigationlAgricultural _ 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 a Replacement Well Li Well Alteration/Modification _ Other <br /> Monitoring Well(s) #of wells 71 Soil Boring(s) #of borings - Geotechnical #of borings <br /> _ Out-Of-Service Well . u Out-Of-Service Well Renewal Lj Cross-Connection RegE. <br /> - New Pump YPump Replacement D Pump Repair Raise Well Casing / '�`i <br /> WELL CONSTRUCTIONc� &- h <br /> Drilling Method _ Mud Rotary a Air Rotary L Auger _ Cable Tool Push Point _ Other /VFd <br /> Proposed Well Depth ft Excavation in diameter _j Open Bottom L Gravel Pac W+Z&1A._ in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft SAA/J [((//��((�� <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched J Steel U Plastic iN4�fr /N C®b <br /> Grout Seal Depth ft n Neat Cement(94/b bag/5-10 gal water) n Sand Cement DEp�4fFtV s, k mix17 gal water 1 <br /> - Bentonite(20%solids) � Other 'WEN T (� <br /> Grout Placement Method - Pumped 5 Free Fall 5 Other Retardant I Accelerator(name) O <br /> PEDESTAL Installed By - Driller D Pump Contractor Other <br /> _ Concrete Pedestal uDimensions:Width ft Lengt ft Thick in _ Christy Box LI Stove Pipe <br /> PuuIP Submersible- Turbine n Other HP Pump Set 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. t 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 /> MI IM M HOUR ADVANCE NOVICE REQUIRED F®�N/S�P,nEC/T�IO{�N/S/-'/PLEASE CALL (209)x95 -7597 <br /> SIGNED TITLE /" � ✓1 lX I 1 I a DATE `�' LY-0 <br /> I I <br /> HA <br /> DEPARTMENT USE ONLY <br /> Application Accepted By � Date 71-NAR-09110 Area -1 1�`� Employee ID# E9 <br /> Grout Inspection By Date C SPECIAL Well Permit <br /> Pump Inspection By c,,�;5 �a.rti:. ;L Date %/wy I._I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Receivedec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Bv Cash Remitted Service Request# <br /> 381 090 0 f77 1• •20 <br /> -WO AU9 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />