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.S ov.or /ehd �,yE�XNPIIRES 1 YEAR <br />FROM DATE TISSUED <br />JOB ADDRESS // /{-_�n,,,�f�.� ✓ trJ� 5' I J' //j� /rtt r� 1 `'N 0 D�P41 CITY/ZIP - aq'c-Y / S 3 7 -,A- <br />CROSS STREE1 Ya a4t, Na�"'� P4. APN 2qV - A 0 PARCEL SIZE 054 LAND USE APPLICATIONN # <br />OWNER NAME 60d t-JATIpazI LLC.. Rirxy auno (urrJ', PHONE b- 235 OL6 <br />OWNER ADDRESS �1 . 4"6 4 '/1'7.'(, �'J� �t� ( �,. 'j CITY/STATE/ZIP M 6ZO Q /^� `• "r� Ol <br />CONTRACTOR W"'t-,h���7L� -k-URL, <br />, to 1'T51cct �fl✓�C.�] PHONE <br />� r )v ~ �0�,'I r13 Y <br />CONTRACTOR ADDRESS 3c) 5-0 jP✓"" u'r'`L� % Lvo. CITr1/'SMTATEIZIP x'1011 <br />C <br />JQQmG -07SUBCONTRACTOR/CONSULTANT 1ji` r`t(LI P"1 •r CfiI <br />►f `+o <br />f oO <br />TRACTORICONSULTANT ADDRESS 11133 i3t41c(WHV(26r QR. \ CrrvISTATE/ZIP faAvr(cA-� <br />i a <br />C-57 C-61 i D-09 (1 lh NUMBER 20C EXPIRATION DATE 1 <br />PARTY: D OWNERCOt.TRACTOR 0 SUBCONTRACTOR/CONSULTANT <br />)OMEsnc WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) D Dibromochloropropane (4392) ❑ Arsenic (4393) <br />NTENDED USE J Domestic/Private a Irrigation/Agricultural ❑ Industrial E 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 New Well I I Replacement Well I I Well Alteration/Modification i Other <br />Monitoring Well(s) # of wellsoii Boring(s) # of borings Geotechnical # of borings <br />I Out -Of -Service Well a Out -Of -Service Well enewal Cross -Connection Repair <br />J New Pump I Pump Replacement ❑ Pump Repair LI Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method 7 Mud Rotary I Air Rotary Auger JjCable Tool I Push Point Ll Other <br />Proposed rill Depth�It Excavation � in diameter r.I Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br />L 1 7 Conductor Casing in diameter / Conductor Casing Depth It <br />Well Casing Diameter in Thickness/Gauge/ASTM Schad L, Steel ❑ Plastic L Stainless Steel J Other <br />Grout Seal Depthri ft Meat Cement 194 lb bag/5-10 gal wafer) a Sand Cement sack mix17 gal water <br />-I Bentonite (20% solids) I I Other <br />Grout Placement Method Numped Free Fall Other? Retardant / Accelerator (name) <br />PEDESTAL/� Installed By I I Driller L/ Pump Contractor J Other <br />A J Concrete Pedestal I Dimensions: Width It Length It Thick in I I Christy Box L Stove Pipe <br />PUMP <br />VX7:1 Submersiblel.: Turbine Other HP Pump Set ft Standing Water Level `ft <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 LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 48 HOUR ADV E NOTICE REQUIRED FOR INSPECTIONS - P EASE CALL (209) 953.769 <br />SIGNED 1 TITLE � �� DATE — - <br />D P TMENT $E N L Y <br />Application 1-7 Accepted By Date <br />Grout Inspectio'By, <br />By Date <br />Pump Inspection By Date <br />Soil Boring Inspection By Date <br />COMMENTS <br />Area q7 <br />EmployeelD#- <br />SPECIAL Well Permit <br />LJ WAIVER Received <br />Constructed Well Depth ft <br />® .. <br />EHD 43.06 6/11/2019 WELL /PUMP PERMIT <br />m <br />D <br />0 <br />A <br />fy/1 <br />CO <br />k6j, M7Y <br />