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 W`WW-Siq0V.0M1ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 35 Q a{ CITY2IP LU) <br /> q p Q / 7In <br /> CROSS STREET l� �e — APN D�l O �rj PARCEL SIZE r LAND USE APPLICATION# � O <br /> G7 <br /> OWNER NAME Q yl A I orz <br /> PHONE <br /> y <br /> OWNER ADDRESS 5 Ave- <br /> 5�CITY/$TATE/LP <br /> CONTRACTORAA 7(( n'<' 0-4ty -S �S 1QC PHONE 2-O <br /> CONTRACTOR ADDRESS ZU Q C/3 <br /> C) CITY/STATE/7JP -k�om rA 95 <br /> 9521,.5,SUBCONTRACTOR/CONSULTANT IV /,A- <br /> I U <br /> �ztqPHONE__ <br /> SUBCONTRACTOR/CONSULTANT ADDRESS J / - CITY/STATE/LP \ <br /> _ I V A <br /> LICENSE --C-57 C-61 D-09 Other NUMBER <br /> -qdx)(19 E%PIRATION DATE 1131112-3 <br /> BILLING PARTY: OWNER .CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DoMEsnc WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392)_Arsenic(4393) <br /> INTENDED USE XDomestic/Private Irtigation/Agricultural -Industrial - Water Quality Monitoring - Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Con1aM Name or Phan.Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil Borings) o of borings Geotechnical N of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum Pum Re lacement um Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling ori Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well If Excavatio in diameter Open Botto Gravel P. /Gravel <br /> Size <br /> in diameter <br /> Con Casing in diameter onductor Casing Depth <br /> Well Casing Diameter_ Thickness/Gauge/ASTM Sched Steel Plastic Stai Steel Other <br /> Grout Seal Depth ft Neat Cement(94 Ib bag/5-10 ga r) Sand Cement <br /> sack mixl7 gal water <br /> Bentonite(209%solids) Ot er <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL lied By Driller Pump C ctor Other <br /> Conc a Pedestal_ thDimensions:WidLength ft Thl n Chris Stove e <br /> PUMP &Submersible Turbine - Other <br /> 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 /> M' �} O L7/N��CE�/N�O/ThCE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7097 <br /> SIGNED �`� j `i • _'f"/"' tea' p <br /> / ! TITLE DATE Z:7 <br /> 6 <br /> T �F�4RF�D4Nry <br /> MFNT <br /> // DEPARTMENT USE ONLY <br /> Application Accepted By �y� Date s , I Area Employee ID# DA <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date�I WAIVER Received <br /> Soil Boring Inspection By Date 7 Constructed Well Depth <br /> COMMENTS ft <br /> PE SC Received Che c <br /> Codes Info Amount Date Permit/ <br /> ash Remitted Service a as Invoice# Well ID# <br /> N38R 05o 7 Z <br /> EHD4M6 6/11/2019 <br /> WELL/PUMP PERMIT <br />