Laserfiche WebLink
WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVNUE-STOCKTON CA 96205.6232(209)4683420 <br /> NON-REFUNDABLE P www.S ov.Or ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> I\, A / - LA <br /> JOBADDRESs V 'V' P ' m <br /> D <br /> CROSS STREET 44` <br /> AIN �y�t'\ �yP"ARCEL LAND USE <br /> �A(P1P/LICA'T�I{Or-N-# 2 z <br /> OWNER NAME "�'l��V1 t✓1 � O' r 1 I ea ws F�� PHON152,C", y�',J_ C�� y <br /> OWNER ADDRESS _C bre / CITYISTATE21P <br /> CONTRACTOR n11 't PHONE C _` 1� 11 <br /> CONTRACTOR ADDRESSL+Lt CITYISTATEIZIP PI.[t/v��, <br /> SUBCONTRACTOR/CONSULTANT V� v PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS Cm'ISTAT P <br /> LICENSE /�L57 C-61 -D-09 Other NUMBER ``' �'PIRATION DATE <br /> BILLING PARTY: .OWNER ..CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:IGeneral Mineral/Coliform Bacteria(4391)Aibromochloropropane(4392) 'Arsenic(4393) <br /> 17 <br /> INTENDED USE 0 mestic/Private "-Irrigation/Agricultural Industrial -Water Quality Monitoring -1 Soil Sampling/Characterization <br /> Public Water System <br /> If difterem from Owner Water System Name Conrad Name or Phone Number <br /> TYPE OF WORK Xew Well _i Replacement Well J Well Alteration/Modification Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(S) 1 of bonngs Geotechnical n of borings <br /> G Out-Of-Service Well ❑Out-Of-Service Well Renewal Cross-Connection Repair <br /> C New Pump Pump Replacement Cl Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling MethodVMud Air Rotary Auger Cable Tool r.Push Point Other <br /> Proposed Well Depth ft Excavation in diameter Open Bottom �.,Gravel PackiGravel Size in diameter <br /> t:Conduc r Casing in diameter / Conductor Cas rig Depth r it <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schede C Steel Plastic Stainless Steel Other <br /> Grout Seal De theft I Neat Cement(941b bag/S70 gal water) _.Sand Cement sack mixll gal water <br /> entonite(20%solids) i Other <br /> Grout Placemenmethod Amped _Free Fall :_.Other ._Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal..Diphensions.Width it Length ft Thick in -Christy Box -.Stove Pipe <br /> PUMP _Submersibles:Turbine Other HP Pump Set ft Standing Water Level it <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 /> MINIM O'A ADVANCE NOTICE REQUIRED F INSP TIONS-PLEASE CALL(2 ) 53-7^/69 <br /> SIGNED / 1 / `/ TITLE ' ` DAT I <br /> Pq YMF <br /> RFCE��Np <br /> AUG 2� ?020 <br /> --]t'2TH p pMEQultv N7q�NTY <br /> AR4#�444 -- T MFNT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By �- T L Date < . ' <br /> � "-;`�� Area �h Employee ID# <br /> Grout Inspection By Data ° " t-V ❑ SPECIAL Well Permit <br /> Pump Inspection By Date G WAIVER Received <br /> Soil Baring InLpction By Date Constructed Well Depth 0 It <br /> COMMENTS <br /> PE SC Received Check#/ Amount PermtV Invoice# Well ID# <br /> Codes Date Info Cas Remitted Service Re uest# <br /> v v=v v <br /> 'S. g t <br /> } O t N� <br /> EH04"6 6/112019 WELL(PUMP PERMIT <br /> I13_71ld3`I <br />