Laserfiche WebLink
WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> / >?� Sia c1di n T cA 95 Z I S L <br /> Joe ADDRESS U � U � /•1 U f�11�/ Cm1LP <br /> W I ANVWO 11 APN 7b?L 6bo-o3 b�- o <br /> CROSS STREET , _G PARCEL SIZE BLAND USE APPLICATION# o <br /> OWNER NAME WU1L/j J C L S `arM(� �J,� /yt PHONE !}� m <br /> UCONTOWNER ADDRESS t'I [-I ah rk- TO np ICU CITYISTATEIMP/' &A'I'e-(A , CA 9533.U-- <br /> CONTRACTOR <br /> RACTOR K ,,roA ^ "I,b>A PHONE <br /> I�, -711S. U2--7t, <br /> CONTRACTOR ADDRESS L C CITY/STATE/7JP_MArAjLCA+ (A 1?5J3tn <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CmISTATE/ZJP <br /> LICENSE L C-57 X C-61 n D-09 Other NUMBER l0 4 27q to EXPIRATION DATE 1OFS1,31 O zo <br /> DOMESTIC WELL SAMPLING: I General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392),.j Arsenic(4393) <br /> INTENDED USE Il DomestictPdvate Irrigation/Agricultural i!Industrial I,Water Quality Monitoring i It Soil Sampling/Characterization <br /> i i Public Water System <br /> If dfferenl from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK I New Well j!Replacement Well i I Well Alteration/Modification n Other <br /> 1 Monitoring Weil(s) #of wells !Soil Boring($) #of borings i Geotechnical #of borings <br /> I,Out-Of-Service Well ❑Out-Of-Service Well Renewal !Cross-Connection Repair <br /> I New Pump i I Pump Replace ant XPump Repair i i Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method !I Mud Rotary Air Rotary -1 Auger ! Cable Tool i Push Point !I Other <br /> Proposed Well Depth ft Excavation in diameter I I Open Bottom i i Gravel Pack/Gravel Size in diameter <br /> !Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad 1 Steel !i Plastic 1 1 Stainless Steel i 1 Other <br /> Grout Seal Depth ft -1 Neal Cement(94 lb bag/5.10 gal water) 1 Sand Cement sack mixll gal water <br /> i Bentonite(20%solids) r1 Other <br /> Grout Placement Method ❑Pumped ❑Free Fail 1,Other i Retardant/Accelerator(name) <br /> PEDESTAL Installed By U Driller rl Pump Contractor I I Other <br /> I I Concrete Pedestal i(Dimensions:Width ft Length It Thick in !.!Christy Box ! Stove Pipe <br /> PUMP !I Submersible urbine it 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, STATEWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CAL( RNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION <br /> MINIM 48 H 5W6�. <br /> A NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7`697 <br /> SIGNED TITLE DATE <br /> EC ►ENT <br /> EIVE p <br /> UG 16 2019 <br /> OAQUIN COUNP-jTY N <br /> Fi DEPARTMENT <br /> D R ENT <br /> Application Accepted By ,v ` Area Employee ID#,I!q:E ' <br /> Grout Inspection By , Date ``1III PECIAL Well Permit <br /> Pump Inspection By V�; y t- . 1'nI�Vw L Date I 1 I WAIVER Received <br /> Soil Boring In pection By Da Const clad Well Depth ft <br /> COMMENTS �i �� <br /> PE Sc Received Check#/ Amount Date Permid Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Re uest# <br /> EHD43-05—tsed4114118 WELL/ MP PERMIT <br />