Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4683420 <br /> NON-REFUNDABLE PERMIT WWW. ov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> i3 a N <br /> Jos ADDRESS � CInRIP Q 1 m <br /> CROSS STREET ly G rO 11. lh4 JA-PN�\{Q^��—I^O/O��Z� __PARCEL SQ��LAND USEAPPLICATION <br /> OWNER NAME ]./ 1--►��A l m Aa f)Chi \ PHONE ill`1—r� !)S=l�J�\J�� <br /> OWNER ADDREss 14 5 W .� a. CITY/STATEIZIP("[C rl mV/(�U I CEA 1 /S(.�L/ a <br /> CONTRACTOR <br /> CONTRACTOR ADDREQSS `30 cRY,sTATE,ZIP m o de s `� C!�963 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTR`A`CTTORICONSULTANT ADDRESS �JCITY/STATTIE/ IPl <br /> LICENSE YC-57 C-61 . D-09 -.Other NUMaER fes+ •O b 1`5 EXPIRATION DATE 5_ Y <br /> BILLING PArx/rte OWNER - CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMEsnc WELL SAMPLING: General ineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE DomestidPrivate InigationlAgncullural Industrial [-Water Quality Monitoring Soil Sampling/Charactenzation <br /> Public Water Sys em <br /> If different from Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORN New Well Replacement Well Well Alterabon/Modification Other <br /> Monitoring Well(s) #or wells Soil Boring(s) n of borings Geotechnical It of bor rigs <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement Pump Repair ::Raise Well Casing <br /> WELL CONSTRUCTION Z J:,c <br /> Drilling Mothod`).Mud Rotary Air Rotary Auger Cable Tool C Push Point C Other <br /> Proposed Well(De`pth ft Excaavab.g7 —in diameter Open Bottom Gravel P.ddGravel Size in diameter <br /> Conductor Casing V264 fist tneler I Conductor Casing Depth Z It <br /> Well Casing, ameter in Thi�*e�sss/Raauge/ASTM Sched Steel ❑Plastic 7 Stainless Steel -'Other <br /> Grout Seal epth lew Neat Cement(94 It,bagl5-10 gal water) $and Cement . sack mix17 gal water <br /> Bentonite 20%solids) C Other (( <br /> Grout Placement Metho Pumped D Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By i Driller Pump Contractor Other <br /> Concrete Pedestal n01 ensions:Width ft Length ft Thick in Christy Box Stove Pipe <br /> Fe—fte Submersible Turbine ; Other HP Pump Set It Standing Water Level ft <br /> I <br /> HEREBY CERTIFY THAT 1 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 /> :)UR!aD: >=NOTICE�RE,QUIRED SPE TIONS-PLEASE CALL(209953-7697 Z <br /> SIGNE A DATE <br /> T <br /> O <br /> S / <br /> U <br /> N 7-y <br /> P <br /> DEPARTMENT USE ONLY T <br /> Application Accepted By / ( C <br /> Date_3!l�'J� Area Employee ID# IJ>� <br /> Grout Inspection By. �I— l Date_-y/� /Z�. SPECIAL Well Permit <br /> Pump Inspection By Date _! 11 WAIVER Received./ <br /> Soil Boring Inspection By Date Constinicted Well Depth ft <br /> COQA ENTS "`t '.J�1 =l..-i <br /> PE SC Received / Amount Dte Permit/ Invoice# Well IDAt <br /> Codes Info B Cash Remitted aService Re oast S <br /> MF <br /> '-13 , f oro Z <br /> EHO 43.06 W112019 WELL/PUMP PERMIT <br /> f.-M a hl ltd/W. d Zo (?0"6 U l Z <br />