Laserfiche WebLink
r <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNnARL�PRRMIT ...�i� ,,,ra/ehd EXPIRES I YEAR/'QOM DATE ISSUED <br /> JOBEADDRES �'f 139�uV+ry1.1N ._. : _ CI1rZ1 1.tJ VL L <br /> (CROSS STREET Pr� APN �y /� <br /> 1/ <br /> TE <br /> L��/'1�" J __. _ Q!VG)Uc7� PARCEL SIZt �9 _LAND USE APPLICATION# A <br /> OWNER NAME �l/� J— V �jD/ --•�/ P�HO�NE �/' / 'fa <br /> �/ .� tn, <br /> OWNER ADDRE ✓ L `� ��( �y,/� W _�_�/� _ CITYISTATE/Zlp � ► l` L vl r, 3 <br /> CONTRACTOR JCt—C�j' �l V1 UrC P�H'O7J'J�E /� V <br /> I VL/ <br /> CONTRACTOR ADDRESS — 4 ✓" V /e'�C —r' CITY/STATE/ZIP N f, <br /> SUBCONTRACTOR/CONSULTAN�K PHON <br /> SUBCONTRACTORICONSUL ADDRESS Y ��TV/ T TEIZJ�p/T� 7 I`y�y <br /> LICENSE C-57 • C-61 D-09 Othertj NUMBER � � v EXPIRAnci AT `L `i <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WEL PILING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) _ <br /> INTENDED USE Domestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner. Water System Name Contac[Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of WPI!S Soil Rorin3(c) tl of borings Gsotecl,nical it of bodngs <br /> Out-Of-Servl tell Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump rX Purnp Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth It Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_—in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ft Neat Cement(94 lb bng/5-10 gal water) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) Other_ _ n <br /> ,Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL tallied By Driller Pump Contractor Other <br /> In <br /> Concrete Pedestal Dimensions:Width ft Lepglh It Thick I_in Christy Box %ove Pipe <br /> r <br /> PUi I <br /> Submersible Turbine Other _ HP Pump Sel, _ft Standing Water Le,, <br /> 1 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. tJ l <br /> MINIMUM 48 HOUR ADVANCE NOTICE REQUIRED FRRINSPECTIONS-PLEASE CALL(209) 53-7697 <br /> SIGNED TITLE DATE �N <br /> I _ <br /> I I I <br /> - -- - - - pYM <br /> � I <br /> I _ A. <br /> kk 08IN <br /> DA ?�?1 <br /> RONM�oUN <br /> DEPARTMENT USE ONLY 7 / /��1 T �FpARTMFN� <br /> Application Accepted By — Date I Area 3 �/ Employee ID# r Ir G <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By- Date:ZZ'12A: WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth_ _ft <br /> COMMENTS <br /> ---------- <br /> PES <br /> ESC nt Received hec AmouPermit/ <br /> D e Invoice# Well ID# <br /> Codes Info ash Remitted S Re <br /> it <br /> EHD 43-06 6111/2019 WELL/PUMP PERMIT <br />