Laserfiche WebLink
SUBCONTRACTOR/CONSULTANT PHONE <br />BILLING PARTY: OWNER CONTRACTOR <br /> PAYMENT <br />RECEIVED <br /> SEP 04 2019 <br /> JOAQUIN COUNTY <br />NV(RONMENTAL <br />HEAL- H DEPARTMENT <br />froar-6"4=) <br />EHO 43-06 6r11/2019 WELL /PUMP PERMIT <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EA.sr HAZELTON AVENUE - STocscroN CA 95205 -8232 (209)4684420 <br />eVi NA er V t el CI- PHONE 2-07- WM- Oi!) <br />Lb 0 CITY/STATE/Zip 4 cevic cc 752.2f) <br />53a - 7 53-7a 25' <br />CONTRACTOR ADDRESS FbI 4i3C5K <-<;:c qo <br />PHONE <br />crivsTATErzip 0 <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE N., C-57 C-61 0-09 Other <br /> CrTv/STATE/Zie <br />N um," Ai IS" Es' EXPIRATION DATE ell /3 (3/12C23;) <br />SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPUNG: ,; General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />TYPE OF WOR%-''.1, New Wet Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of webs r Soil Boring(s) fl of bainos Geotechnical tr or borings <br />Out-Of-Service Well L Out-Of-Service Well Renewal Cross-Connection Repair <br />New Pump ' Pump Replacement 0 Pump Repair Raise Well Casing <br />Other Retardant / Accelerator (name) <br />Installed By Driller , Pump Contractor Other <br />Concrete Pedestal 'Dimensions: Width ft Length ft Thick in Christy Box Stove Pipe <br />fl Standing Water Level ft Pump Set Submersible:, Turbine . Other HP <br />WELL CONSTRUCTION <br /> <br />Drilling Method ." Mud Rotary :I Air Rotary ::'i Auger ‘Nly Cable Tool "L Push Point '• Other <br /> <br />Proposed Well Depth 600 ft ) / G In diameter Nie Open Bottom 'I Gravel Pack/Gravel Size in diameter <br />Conductjpi?Cesing -2-7,1 in diameter / Conductor Casin Depth 5 ft <br />Well Casing Diamei in ThIckness/Gauge/ASTM Schad.2--S l' "Ve' Steel '. Plastic ..: Stainless Steel,1. Other <br />ba <br /> <br />Grout Seal Deptt"...,... ft .1" Neat Cement (94 lb g/5-10 gal water) "s ?Sand Cement /0. 3 sack mix/7 gal water <br />' Bentonite (20% solids) ' Other <br />Grout Placement Method\ Pumped - Free Fall <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 UCENSE BOARD AND THAT I AM IN COMPUANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />_.,ZtA 48 HOU2,AE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95,3-7697 <br />T TLE Q-.)(k) DATE / <br />Application Accepted By <br />Grout inspection By <br />Pump Inspection By <br />Soil Boring Ins <br />COMMENTS <br />43P1 2. <br />Area <br />%A; LL <br />11) C-nci. • <br />bet(Employee ID# <br />Date <br />Date <br />Date <br />0 <br />n By <br />r-V.,t)INA <br />AT ENT US 0 LY <br />.411X <br />"111112041/ 'war • <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth <br />PE <br />Codes <br />SC <br />IN,:; <br />ReceivedCheeldri <br />Cash ,....--- <br />Amount <br />Remitted Date Permit <br />Service Repast # Invoice # Well ID# <br />(4267(r tj <br />iii, <br />2---- 1,1 i pO cii ,i119 V I <br />SIGNED cc 4 <br />JOB ADDRESS <br />CROSS STREET(Frilk t. lig APN al3O PARCEL SIZE LAND USE APPUCAT1ON <br />NON-REFUNDABLE PERMIT www.s7v.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED <br />E ciTy cam(' 2:2-C3 <br />INTENDED USE Domestic/Privat#N, IrrigatioNAgricultural ", Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Oemer: Water System Name Contact Name or Phone Number