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 .S ov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1 S = J h&',1+ aG_,1z3io rV(L U CITY/ZIPo, � xnlt%) ,I d t' 6154) m <br /> CROSS STREET A"Vi �� APN O fl ^ © `� / D <br /> '� � PARCEL SIZE LAND USE APPLICATION# <br /> OWNER NAME C,/�1y /" �JLl+�`�� ld PHONE X09 6442-- 34 79 m <br /> N <br /> OWNER ADDRESS l�©y c� 3�aHP� YI • CITY/STATE/ZIP (`Ci7��1�]O ��v 1P•� <br /> CONTRACTOR PHONE <br /> CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 C-61 D-09 Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: OWNER I I CONTRACTOR I SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: L General Mineral/Coliform Bacteria (4391) ❑ Dibromochloropropane(4392)❑ Arsenic(4393) <br /> INTENDED USE Domestic/Private Irrigation/Agricultural I 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 I I New Well I I Replacement Well I I Well Alteration/Modification I Other <br /> I Monitoring Well(s) #of wells I I Soil Boring(s) #of borings I i Geotechnical #of borings <br /> (Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement C Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ! 1 Mud Rotary I1 Air Rotary i Auger Cable Tool I I Push Point i Other <br /> Proposed Well Depth ft Excavation in diameter I Open Bottom 1 I Gravel Pack/Gravel Size in diameter <br /> L Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched L Steel L Plastic Stainless Steel J Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement sack mix/7 gal water <br /> i 1 Bentonite(20%solids) I Other <br /> Grout Placement Method I I Pumped i I Free Fall 11 Other i i Retardant/Accelerator(name) <br /> PEDESTAL Installed By 11 Driller _ Pump Contractor L Other <br /> Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> PUMP Submersible) 1 Turbine 1 i 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, 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 /> 'MUM 48 TUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL(209)953-7697 <br /> SIGNED �l L J� J fes(_, �`1 TITLE 0W IV DATE _o�� Ao <br /> SAbLjQAC Ull C U <br /> ENVIRON ENTAL <br /> EP TMENT SE ONLY <br /> Application Accepted By Date � Area Employee ID# <br /> Grout Inspection By / Date I SPECIAL Well Permit <br /> Pump Inspection By 1reg2U i c(a bq _ Date (L7 y� ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount patp Permit/ Invoice# Well ID# <br /> Codes Info C Remitted Service Request# <br /> 24 It W-2w(M <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />