WP0042236 - Laserfiche WebLink

Home Browse Search

WELUPUMP PERS SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205.6232(209)468-3420 NON-REFUNDABLE ^JPERAIIT ^_,.,/ _ WWW.Si riv.oT /ohd EXPIRES f YEAR FROM DATE ISSUED JOB ADDRESS (l 3 A J ILLG( U/9 Q ^ C r lz, ST-DC[�G�,-� JSzoS m CROSS STREET S j'GLl M OI'L� /r7 t/E APN ! ` J ` -'J` I J✓ PARCEL SIZE LAND USE APPLICATION it apo OWNER NAME C 1-7-Y O S S C,K.7-0/JT-0 r ` C �,/ PNONECZ�9) `q 3�-�7�( Szl✓Z 1n° OWNER ADDRESS 1 7-J N E L' D O��-D O S r RYISTATERJP S 1 �+G i a 1) C A { CONTRACTOR 7"1L I - C-O L "I r y 2)L•L► ,J /N C d �J /+ /� .y PHONE rUS�� - CONTRACTOR ADDRESS �.yr7��) `� I D A S 1 CITY/STTATTE21P S„'N 0)-16-0. e,4 9z/2 6 SUBCONTRACTOR/CONSULTAM / ) >°I pp� A�D CO,&(Z-V S 10 AJ SIP ems.{ a 1,—,7f I p�d)S y Y-3 Z-3 Z SUBCONTRAC_TO`R/CONSULTAM ADDRESS 837 i1 Tu 1-Pif4rS HCJL� "4115-TSA-T7E/T�,'7M� a-AjYJLLE LICENSE W' -57 - C$1 D-09 -Other NUMBER 5'4` //J , E%PIRATION DAR 0 �a Z 2- LUNG LUNG PARTY: C OWNER C CONTRACTOR SUBCONTRACTOR/CONSULTANT DoMEsTIC WELL SAMPLING;U General Mineral/Coliform Bacteria(4391)❑Dlbromochloropropane(4392)U Arsenic(4393) INTENDED USE -OOmeStiC/Pr1Vate 0 Irrigation/Agricultural C Industrial ❑Water Quality Monitoring 7 Sol Sampling/Characterization 7 Public Water System If different from Owner. Water System f.artn Contact Name or one Number TYPE OF WORK New Well i I Replacement Well I Well Alteration/Modification 14-Other O IG GT7UN -1 Monitoring Weil(s) 4 Of wells F Soil Boring(s) s of borings r Geotechnical i out-Of-Service Well L Out-Of-Service Well Renewal i Cross-Connection Repair :3 New Pump 7 Pump Replacement D Pump Repair D Raise Well Casing WELL CONSTRUCTIO�N Drilling Method *'lviud Rotary G Air Rotary U Auger C Cable Tool 7 Push Point C Other (Proposed Well Depth s ft Excavatl°n /Z In diameter :-Open Bottom Gravel Pack/Gravel Size in diameter 7 Conductor Casing In diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Schad C Steel C Plastic 0 C'> 1e,e, �rNber iGrout Seal Depth_Zt: ft 0 Neat Cement(94/b bagl5-10 gal water) NS`and Cerner' y it)-.3 Sack mr-gal wafer -1 Sentordte(20%solids) n Other Grout Placement Method G"Pumped -Free fall l Other Retardant f Accelerator(name) PEDESTAL Installed By D Dnller C Pump Contractor 0 Other i -1 Concrete Pedestal❑Dlmenslonz:Width ft Length-h Thick In ._Christy Box Stove Plpe uMP Submersibie0 Turbine G Other HP Pump Set It Standing Water Level It I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLUINCE WITH ALL WORKERS COMPENSATION LAWS. �� /1 x/19 HO R A ;V7/rANrEE NOTICE REQUIRED FOR INSPECTIONS •PLEASE CALL(2Q9)953- 697 SIGNED ✓V-`-"-""� �✓''- TITLE O• 44�0"Urjs /;12-oz 1 SMF UIF 01 Do pgR �NTY NT DEPARTMENT USE ONLY n Application Accepted By /� � Date 7 / ,.7( Area�:�fC�k�`” Employee IDq Grout Inspection By L __ Date O C SPECIAL Well Permit Pump Inspection By Date 0 WAIVER Received Soll Boring Inspection By Date Constructed Well Depth 1t COMMENTS PE Codesrmitf Info eye e h Remitted e 1 Serviu R oast tl Invoice Ti Well tD1 14 V ') EHD 430E W11/2019 /� WELL/PU%1P PERMIT