WP0041518 - Laserfiche WebLink

Home Browse Search

CA f► ' WELL/PUMP PERMIT SAN jOAQUIN COUNTY ENVIRONMENTAL HEALTH FJEPARTMENT '1868 EAST HAZELTON AVENUE•STOCKTON ON CA 95205-6232 (209)468-3420 NGN;-REFUNDABLE PERNUTiV. S ov.orglehd EXPIRES 1 YE#R FROM ATC ISSUED JOU ADDRES�i __—..---- - (/l _— - m CROSS STREET_ 6i 1l 10 Fe _ _ Al�t+i r�147/�I v 0(, ---_--PARCEL SIZE -7110 LAND USE APPLICATION# 1 WVI / _ J m OWNER NANIr _—.__...- ---- Pt�ortE __—"I OWER ADDRESS 1 LJt CITYISTATE/!SP - b6t rS e•n Ch1 S SUl 'HONE c '1 a T �j�J 1�I/�� U� i CONTRACT OR ADDRESS DV -I. ! A��l—�1�^'1 _ CITYISTATE/PIP—� �P �5 ?`5 ( '- J .. I SUBCONTRACTORICONSULTANT PHONE'• `^ i i SUBCONTRACTOWCONSULNA NT ADDRESS •—_-- J — — CITYISTATIEI.Zf IP, (_J_'1 J i _ C•: SCG r4 t �(� NUMBER ^y �a" EXPtRAT1ON DATE �/ 1 �� Z D *!CENSE .5 6i _ D-09 _ Oher --.-- BILLING PARTY_ OWNER ONTRACTOR SUSCONTRACTOWCONSULTANT -- I D»11MEs77C MELL SP.AltPL4NG: _General Mineral/CclilOrm Bacteria(4.391; _ Dihromochioroprae,ane(4392, _-. Arsenic,1439 i iNTENNV D USE industrial _ 'vilater Quality Monitoring _ Soil.Sampl ng%Characterzation - Public Water System If different from Owner. Water System Name Contact Name or Phone Number TYPE OF WOR-_ New Well Replacement Well -- Well Alteration/Modification _ Other - Monitoring Well(s) #of wells - Soil Boring(s) #of borings - Geotechnical #of borings ;_?Dut-Of-Service Well, Out-Of-Service Well Renewal _ Cross-Connection Repair m New Pump Pump Replacement _ Pump Repair = Raise Well Casing 1 kAIELL CONSTRUCTION I riliing Methred _ Mud Rotary Air Rotary - Auger _ Cable Tool _ Push Point _ Other I Prepr-Sed Weil Dapthft:=. Excavation .•�__ __ in d;amete,* : Open Bottom _ Grave! PackJGravel Size— in diameter _ Conductor Casing -_in diameter 1 Conductor Casing Depth--•___.,-_ :t 'Ah-,11 Casing Diameter__-_ in Tf,icKnpss.'Gaugei-t-,TU?Sched•-_---.----•-. Steel P!astir, Stainless Steel Other— ! n G:oLlt Seat Depth-_ ft• Neot Cement(94 lb be, 90 gal vvsler) Sand Cement___ --_--sack mix17 gal water)' Sl Bentonite(20%solids) ' Uther Grout Placement Method_ Pumped .- Free'rail - "_Other - - - Retardant l Accelerator(name) J j PEDESTAL Instalied By -_ Driller Pump Contracts Other _ Concrete Pedestal Dimensions:Width ft Len th ft Thick in _ Christy Box _: Stove Pipe j - _ L;MF - Submersible- Turbine Other HP Pump Set ft Standing Water Level _rt C7I HEREBY CERTIFY THAT 114AVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THIS CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPEN' °'TI N LAWS. IA y E1Pg4�Qi 1'ItQ .j-*,SIL e��•�, IFiNC IF'I 'rP *'.e. .f�R%'14uwavl O 1S � it� r- � { 0 [fit, ?S�EI`^3A!'J7€ t:'. ��i.d S.. '.:fir r',f S•w•I,. I'v. �S'..•r,: r't�:5.f:�.:1 ,.�'C..% I.:1J1"!. '� vaYk�'.•�M7 vF-I.....F'.JL' .N9�. V`�d��.�l.,d "I69t SIGNED -- 11'LE _ _ DATE I I -t-�-- --I +TI -i - r-' -Li SAN JOA RNET DEPARTMENT USE ONLY CF:NT= Application Accepted By �� Date cc- P-0 Zb Area y rJr Employee ID# FISn Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By (r�nC�Slo �Qsrrt�t, ` Date 1,0 1 ! WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS ALjn 1'jc7 PE SC Received Check#/ Amount Permit/ Codes Info Cash Remitted Date Service a uest# Invoice# Well ID# EHD 43-06 6/11/2019 7 d 7l //_!, WEI I TPI IMP PFRAAIT