Laserfiche WebLink
Y(4 ..W51 <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4683420 <br /> NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> (` S /T 1 fA <br /> JOB ADDRESS VJl Fi. L<xkc--Fo,J 54 re CITYIZIP Lod;/9Sayo m <br /> / D <br /> CROSS STREET C h el ake a APN 043 ;Lu 1–04 1 PARCEL SIZE LAND USE APPLICATION# p <br /> OWNER NAME Keo 1'1e. L U)'16 <br /> PHONE <br /> OWNER ADDRESS 340 jcme CITY/STATEIZIP iori) 95-49 V <br /> CONTRACTOR Terrwce . PHONE ;.oeI-367-3 <br /> 7ei <br /> CONTRACTOR ADDRESS qOa- uS+P/4rlu'AI CITY/STATE/ZIP FOjr <br /> or <br /> A-A / gsatio <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP i <br /> LICENSE l C-57 C-61 D-09 Other NUMBER �690 `oy E%PIRATION DATE JIJ1 f�I <br /> BILLING PARTY: OWNER CONTRACTOR I SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(439 ) Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name of 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 Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth 10 S ft Excavation t4 in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thicknes;{Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth 10 115 ft Neat Cement(94 lb bag/5-10 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 ft Length ft Thick in IChristy 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 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 /> NIM 48 48 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209t-)953-7697 <br /> SIGNED TITLE e)CDI/Or4;dr'MAMa L DATE <br /> tjli PA <br /> YW 10 <br /> l VED <br /> EC 2 z 2010 <br /> DAQU/ly C <br /> / 0e M ��n' <br /> J JJDEPARTMENT USE ONLY <br /> Application Accepted By L� !— Date_1d dd J2 Q Z0 Area L�'�) Employee ID# .� <br /> Grout Inspection By 4. A, Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> 7 JS0 4Coe Lyle <br /> EH043-06 6/11/2019 WELL/PUMP PERMIT <br />