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.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS CK S, -AY,4h 1 Vv CITY/ZIP t 1 v`C/`A m <br /> ) C �/1 D <br /> CROSS STREET f1 APN�I 6 D{ S oZ PARCEL SIZfi�J LAND USE APPLICATIO2N(#� ( Y1] <br /> OWNER NAME �� J� /► ' " v► Y'`7+-� {yP.}HONE`I�`�, moo,~. //J J��/ynJ� I N <br /> OWNER ADDRESS !/�� �{ '` CITY/STATE/ZIPV�w/�w/� - V" f �� I <br /> CONTRACTOR lam/` I'�/n�/l �t (�` n� D `PnHOON�E D-C) �- ` i ['X. -)I <br /> CONTRACTOR ADDRESS ` v '✓`�/� `I H'-1 Le" CITY/STATE/ZIP1_`V`e V L''7611 � \ <br /> SUBCONTRACTOR/CONSULTANT I ✓� PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE /(C-57 CI C-61 D-09 ❑ Other NUMBER EXPIRATION DATE �� I <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/Private U Irrigation/Agricultural ❑ Industrial .7 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 ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings 11 Geotechnical #of borings <br /> ❑ Out-Of-Service Well 1 I Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement i Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary ❑ Air Rotary - Auger Cable Tool _I Push Point Other <br /> Proposed Well Depth �,0 D ft Excavation — in diameter LlOpen Bottom I I Gravel Pack/Gravel Size in diameter <br /> LiCondu or Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sche Z El Steel Mastic IJStainless Steel f_I Other <br /> Grout Seal Depth J� ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) I1 Other <br /> Grout Placement Method mumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller Pump Contractor I I Other <br /> ❑ Concrete Pedestal❑Di ensions:Width ft Length ft Thick in ❑ Christy Box 1_I Stove Pipe <br /> PUMP ❑ 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. 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 /> WORKERS COMPENSATION LAWS. <br /> MINIM UR^^ADVANCE NOTICE REQUIRED FOf� IIN/SP�CTTIONS -PLEASE CALL(209)953-7'6n9 �'\ <br /> SIGNED TITLE ✓� ` DATE � I lY '�LJ <br /> r <br /> Ad <br /> M."A4 . <br /> rA <br /> T <br /> / DEPARTMENT USE ONLY <br /> ' <br /> Application Accepted By /`� v Date 'Se o \ Area .� fir Employee ID# c,I Ih <br /> Grout Inspection By �,t a6,U11 ,lam Date a(2,n2 u SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received/ <br /> Soil Boring Inspection By Date Constructed Well Depth .�V 0 ft <br /> COMMENTS t17l� � -ZD a ►" l g'- �( y`z t� <br /> PE SC Received heck Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B as Remitted Service Re uest# <br /> tv 2u i 1 ?;6 <br /> 3V i o y2o I� u <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />