Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
RTMENT7E„OiNLY <br />Date ,9 74,20 Area Z /1. Employee ID# C14 /1/421—') <br />Date <br />Date <br />Date <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <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.sigov.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 3 95 Z crryizip Get 9.7z:s--• `11, <br />CROSS STREET eT/Iitici—E—APN Z 0 CO I PARCEL SIZE ' g -AND .1 — A PPLICATION # I I 0 <br />OWNER NAME COAAJ7 13/// 1.4101.7* /1h4"T'j>z SHONE 2 <br />OWNER ADDRESS jCk ec 39 zVef cnysTATEmp <br />CONTRACTOR <br />CONTRACTOR ADDRESS IV/ITV/STATE/ZIP <br />SUBCONTRACTOR/CONSULTANT <br /> <br />PHONE <br /> <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br />,irellTio4 LICENSE Li C-57 El C-61 Li 0-09 L Other NUMBER <br /> <br />EXPIRATION DATE <br /> <br />BILLING PARTY: D OWNER PLaiNTRACTOR El SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL WELL SAMPUNG: _ General Mineral/Coliform Bacteria (4391) _ Dibromochloropropane (4392) Li Arsenic (4393) <br />INTENDED USE D Domestic/Private C Irrigation/Agricultural Industrial 0 Water Quality Monitoring Soil Sampling/Characterization <br />0 Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK LI New Well Li Replacement Well <br />0 Monitoring Well(s) # of wells 0 Soil Boring(s) s of borings Geotechnical # of borings <br />D Out-Of-Service Well n Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />0 New Pump "VISump Replacement 0 Pump Repair 0 Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method Li Mud Rotary n Air Rotary 0 Auger Li Cable Tool El Push Point u Other <br />Proposed Well Depth ft Excavation in diameter Li Open Bottom 0 Gravel Pack/Gravel Size <br />0 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 0 Steel 0 Plastic 1, Stainless Steel L. Other <br />Grout Seal Depth ft D Neat Cement (94 lb bag/5-10 gal water) Li Sand Cement <br />Li Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped E Free Fall Li Other D Retardant/Accelerator (name) <br />PEDESTAL Installed By _ Driller Li Pump Contractor ID Other <br />Concrete Pedestal 0 Dimensions: MAdth ft Length ft Thick <br /> in 0 Christy Box 0 Stove Pipe <br />PUMP c *gubmersible - Turbine Other HP 3 Pump Set ft Standing Water Level ft <br />I HEREBY <br />e <br />RTIFY 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 />MI <br />l-7/7/0--t /7 .z-t, <br />E NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209)43-Th97/ <br />TITLE DATE <br />Pl7)11-12 73/-63 <br />sack mix/7 gal wat <br />SIGNED <br />P4 16,. Li 'Nell Alteration/Modification 0 Other <br />C‘ 4.k.A <br />/fr <br />0 4, '7 <br />944rnp .96 2020 <br /> 04,0 cot,. <br />7;014' 7-4,4t <br />...••••• <br />A./F-T-4-47frt/ <br />11. 1 <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />p o co-Lc, <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By,. <br />C41 e <br />as <br />Amount <br />Remitted Date „ <br />Permit/ <br />Service Request # Invoice # Well ID# <br />45i1 05-o /6m7 -4_3_ 3111qm wpoo Li au e&--' <br />END 43-06 6/11/2019 WELL RUMP PERMIT