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�DAATE ISSUED <br /> J08 ADDRESS i� CITY/ZIP /// 9-7 <br /> yyyy�� ^�j-� A <br /> CROSS STREET /�� /� APN Z1j— t✓VPARCEL SIZE 6#1 LAND USE APPLICATION# <br /> OWNER NAME / O� PHONI ayi <br /> OWNER ADDRESS rD�yt� lvD _ CITY/STATE/ZIP <br /> CONTRACTOR // w �If�/�s �/�� — PHONE % <br /> A 3z�� J7i � <br /> CONTRACTOR ADDRESS ZIP �/�L /2„�� CITY/STATE/ZIP_ <br /> SUBCONTRACTOR/CONSULTANT__ PHONE- <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE OC-57 ,mac-61 ❑ D-09 ❑ Other NUMBER EXPI TION DATE <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑ Dibromochloropropane(4392)0 Arsenic(4393) <br /> INTENDED USE )gDomesticdPrivate ❑ Irrigation/Agricultural ❑ 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 ❑ 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 ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Schad ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mW7 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 (f <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP % Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br /> ofy <br /> I HEREBY CERTIFY THAT 1 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 /> Wr�M8ADVANCE NOTICE REQUIRED FOR I SPECTIONS-PLEASE CALL(209)93-7 7SIGNED ��` TITLE DATE%A0 MV <br /> 4120 <br /> O (,Z <br /> H MEN <br /> T <br /> DE AR MENT S1q4 ,( / (�j( <br /> Application Accepted By eate Area Employee ID# �4 (jl- v <br /> Grout Inspection By Date .I SPECIAL Well Permit <br /> Pump Inspection By Date D WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well npnth ft <br /> COMMENTS Qun, _{1vrw� _ `}�Prnt,v p netl�f d �,t�er WIPCO q01 SS 0A1Pfiq Q2a. t'6 Q <br /> PE SC Received hec Amount Permit/ <br /> Codes Info B Cash Remitted Dat Service Re uest# Invoice# Well ID# <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br /> SII <br />