Laserfiche WebLink
r } <br /> 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.sjgciv.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADD0.ES5oo( CITYIZIP L <br /> m <br /> D <br /> CROSS STREET APN n a PARCEL SIZE LAND USE APPLIC TIIONN## p <br /> OWNERNAME 1 JI 11!1�it7Jl l� l.J/► ./� PHONE Vi/�',{ /s <br /> OWNER ADDRESS v- � me,I�rJa,, CRY/STATE/ZI' , y ��r�I�/��fI I-� ML-161W 1;1J^7 <br /> CONTRACTORM10 PHO 0 ML_�i!>JL.I <br /> I <br /> CONTRACTOR ADDRESS CITr/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTAN7 h�S\ PHONE N <br /> SUBCONTRACTOR/CONSULTANT ADDRESS \ W CITY/STATE/ZIP <br /> LICENSE /C-57 C-61 D-09 Other NUMBERj%1 Lk5 EXPIRATION DATEy , -LO� <br /> ) � <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> DomestictPrivate Irrigation/Agricultural Industrial Water Ouakty Monitoring Sal Sampling/Characterization <br /> Public Water System <br /> r!r <br /> M Qrlf—t hom Om, LVater Sole,Name Contact Name w Prone Numbe, <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) #of wells Soil Boring(s) a oroonngs Geolechnical aofbonngs <br /> xOut-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repa r <br /> New Pum Pum Replacement Pum Repair Raise Well Cats <br /> in �`' \qp-(itim=116 <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth fl Excivation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth It <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94/b oag15.10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions,Width II Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible Turbine 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 AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND AC VE WITH NIA CON ACT RS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPE TION S. <br /> MINIM O D FOR IVVCTIONS-PLEASE CALL(209 9 3-7697 <br /> SIGNED TITLE VV DATEZO 2L. <br /> I IF RE YMFNT <br /> VFO <br /> 40G 24 20 <br /> RQ U/At C� <br /> TN�PARTMENry <br /> DEPARTMENT SE ONLY <br /> � <br /> Application Accepted By �G Y-- Date a O���'L) Area Employee ID#_ <br /> Grout Inspection By (� Date SPECIAL Well Permit <br /> Pump Inspection By t4 q&f% LL Dale k0(Ij.j'IAW WAIVER Received <br /> Soil Boring I #action By Dale Constructed Well Depth H <br /> COMMENTS t'Y s Ilt ' i ll S r/ [ )! S oir; �Y r/P Or')YT • f <br /> Ili-0111 t t a i n-c-ow - - <br /> PE SC I Received Check#/ Amount Date PermiU Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Re uesI# <br /> y <br /> EnD+3+:6 6112919 �oWELL,Pu?JPPERMIT <br /> � <br />