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-REFUNDABL P MIT S OV.Or /ehd EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS ` CITYIZI Cc, (1 L <br /> I <br /> CROSS STREET in e q APN jR073j o i 6 PARCEL SIZE__LAND USE APPLICATION#2 Q q <br /> OWNER NAME PHONE <br /> OWNER ADDRESS \ CITY/STA G <br /> CONTRACTOR + � J— PHONE �9 �V� <br /> CONTRACTOR ADDRESS CITY/ TA <br /> CC4 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR./CONSULTANT ADDRESS I 'STATEOP �J <br /> LICENSE C-57 Vr61 D 09 Other NUMBE �� EXPIRATION DATE O _ <br /> BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WEN!.#—!PUNG: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE omesticlPrivate Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> L <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> Monronng Well(s) #of wells Soil Bodng(s) *of bonny' Geotechnical sof borings <br /> Out-Of-Service Well .,,Out-Of-Service Well Renewal Cross-Connection Repair - n <br /> New Pump Pump Replacernenj,!!nk-Pump Repair Raise Well CasingvU( <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth ft 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 Schad Steel Plastic Stainless Steel Other _ Z • <br /> Grout Seal Depth ft Neat Cement(941b bag/5-10 gal water) Sand Cement sack mi)/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method Pumped Free Fall Other Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal Dimensions:Width It Len it Thiclt in Christy Box Stove Pipe <br /> PUMP Turbine Other HP Pump Set ft Standing Water Level ft 1 <br /> , HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STAT WS, AND RULES AND REGULATIONS, I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CAL IA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. ` <br /> NI U OUR CE OTICE R UIRED FO INSPECTIONS-PLEASE CALL(209)(209)!77697 (w <br /> SIGNED TITLE ,� DATE v <br /> t I <br /> T- <br /> f2 TI <br /> IWV L i I <br /> —j 2YMEN <br /> a 40 <br /> CES�E� <br /> 011 <br /> 4 2021 <br /> QU/N co <br /> NMENTUNTy <br /> j DEPARTMENT U E ONLY �j APARTMENT <br /> Application Accepted By`- �" _ Date �4�)/ Area I mpioyee!D# (;_ <br /> Grout Inspection By Date _ SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring In ection By Date_. Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount DatePerm t/ Invoice# Well ID# <br /> Codes Info B �_ Remitted 'er✓i a Re uest# <br /> s< - <br /> 3 a <br /> I — <br /> EHO 43-06 6/1112019 WELL/PUMP PERMIT <br />