Laserfiche WebLink
PHONE <br />JOB ADDRESS <br />CROSS STREET <br />OWNER NAME <br />NON-REFUNDABLE PERMIT www.sjgov.org(ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />aid 1,46,1-c-c FJ- ApN ii in 33 PARCEL stzE3tjleAND USE APPLICATION ri <br />() 1 16 —/ EC/ 54— /Lictiyi sf f crrya,p <br />1-'2it-Q--r D ic4F <br />Contact Name or Phone Number <br />INTENDED USE 1 Domestic/Private 0 Irrigation/Agricultural C Industrial 0 Water Quality Monitoring Soil Sampling/Characterization <br />1 Public Water System <br />If different from Owner. Water System Name <br />TYPE OF WORK I New Well ii Replacement Well Well Alteration/Modification I Other <br />P Soil Boring(s) # of borings j Geotechnical of borings <br />L Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />Monitoring Well(s) # of wells <br />J Out-Of-Service Well <br />3 New Pump 3 Pump Replacement 0 Pump Repair 0 Raise Well Casing <br />1) ec/ -!-11-61/11 <br />SE ONLY <br />Area LI/ / Employee ID# <br />SPECIAL Well Permit <br />ill WAIVER Received <br />Constructed Well Depth <br />Dfb <br />ft <br />c64115: 121s 9241573 WELL /PUMP PERMIT END 43-06 6/1112019 <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />DOMESTIC WELL SAMPLING: 0 General Mineral/Coliform Bacteria (4391) o Dibromochloropropane (4392) D Arsenic (4393) <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'ADVAtPE NOTICE REQUIRED FOR INSPEpONS - PLEASE CALL (209) 9531697 <br />r '1/ D ATE <br />R <br />JoPiskA <br />::E:I::MAR10 202T1 <br />y 11E4 iPoN pi au. M ENTAL pAR Tmeivr <br />saw <br />SIGNED TITLE <br />DEPARTMENT <br />Application Accepted By l\e±e—r/jE/Z'IZ----- Date <br /> <br />Grout Inspection By , Date7f-\,. <br /> <br />Pump Inspection By Date <br /> <br />Soil Boring Inspection By Date <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />Check#/ <br />,.• Cash <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />437 c2_150 0.40,1 vicji4 f1061 110114 N V)04 I ig7 <br />OWNER ADDRESS <br />CONTRACTOR 1C)6 kt le,0 ce• Tic- PHONE Cla Cr) , 11 t - 13'f c <br />7,920 1 Arc,K Ai ?oort Rd- 5- - el ITY STATE/ZIP 54kaiv4 CA" .9S. W6 CONTRACTOR ADDRESS <br />SUBCONTRACTOR/CONSULTANT (17 — -- ex L.f.k Su, Su wr. fCAC C., PHONE (D6) 7,6 1 — <br />SuBCONTRACTOR/CONSULTANT ADDRESS IS/D /5 cora._ Ce-Y/STATE/ZIP 2,-Y 0fr k Ci9 <br />LICENSE „ji. 0-57 r C-61 17 D-09 -I Other <br />BILLING PARTY: 0 OWNER 6/CONTRACTOR <br />CrrYISTATEIZIP <br />NUMBER CtuSlf W 7 EXPIRATION DATE 07 )311 Zzzl. <br />SUBCONTRACTOR/CONSULTANT :SS3HCIOV 311S