WP0042312 - Laserfiche WebLink

Home Browse Search

` WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED CA JOB ADDRESS 1-In t Y%QU1I I4TT•I 13M V CIN/ZIP aa� CROSS STREET C,hQrakl2e Q�TAPyN�11111-250-04P PARCEL SIZE 2A fKINO USE APPLICATION# A - OWNER NAME �/QM r"�V WC PHONE �1 /�Q, �j to OWNER ADDRESS /1O •- -� W J CITY/STATE/ZIP � /V -j,� CONTRACTOR V W W(``1 PHONE C O '4(03'-1-t0 CONTRACTOR ADDRESS dr& CIN/STATE/ZIP S637, SUBCONTRACTOR/CONSULTANT -Wallag- 141bi X koaalejPHON,E'1qa�lb 37 -lj{ �SUBCONTRACTOR/CONSULTANT ADDRESS "v � GL�\i IQ I N CITY/STATE21P�b7ytXAL_r Ifo1097^�-N LICENSE M/C-57 ❑C-61 13D-09 Ll Other NUMBER�0 EXPIRATION DATE 1 1(b'22 BILLING PARTY: ❑OWNER D CONTRACTOR SUBCONTRACTOR/CONSULTANT DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)❑Dibromochloropropane(4392)❑Arsenic(4393) INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial D Wa4ter Quality Monitoring irSoil Sampling/Characterization D Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other D Monitoring Wells) #of wells oil Boring(s) #of borings Geotechnical of borings ❑Out-Of-Service Well a vut-Of-Service Well Renewal O Cross-Connection Repair ❑New Pump ❑Pump Replacement D Pump Repair ❑Raise Well Casing WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary 4Auger ❑Cable Tool ❑Push Point ❑ Other Proposed Well Depth t5-1S It Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth It Well Casing Diameter �ein Thickness/Gauge/ASTM Schad C1Steel D Plastic ❑Stainless Steel ❑Other Grout Seal Depth"–/.J ft t(Neat Cement(94/b bag/5-10 gal water) ❑Sand Cement sack mixn gal water ❑Bentonite(20%solids) D Other Grout Placement Method ❑Pumped [Free Fall N'Other U10 Re rt eF era or(name) PEDESTAL Installed By ❑Driller D Pump Contractor D Other ❑Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible❑Turbine ❑Other HP Pump Set ft 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MI Up 48 H UR N ADVANCE NOTICE REQUIRED FOR PECTIONS-PLEASE CALL(209)9553-7697 SIGNED ' TITLE DATE k"JIMN'T NED 0 2021 ll1N COUNTY ONMF rA NT pEPAR DEPARTMENT USE O L)Y S Application Accepted By Date—712 ID / Area I SiewonEmployee ID# r Grout Inspection By Date ElSPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well De th ft COMMENTS Qll [I� PE SC Re iv / Amount Date Permit/ Invoice# Well ID# Codes Info Cash Remitted R ues # 3 SO o 13 o EHO 43-06 6/112, 407/9 WELL/PUMP PERMIT /� ;