Laserfiche WebLink
WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />AInKI D—....-- IT D.—T \MMIU cinnv nrn/ahrl FXPIRFS 1 YFAR FROM DATE ISSUED <br />JDBADDRESS 9� /` ;4^#V lr Ra 407-5/40CITY/ZIP <br />d 4eAN'leo, .ed 9�Z� <br />CROSS STREET " el �� U� «-� c Rd APN - clI PARCEL SIZE 54C-tLANO USE APPLICATION # f <br />(OWNER NAME /l'✓/N �I�/LL�PJ 1 PHONE�`SEPVO <br />. G5 � L� <br />OWNER ADDRESS �S77A$7- �%/}fff}-iVT Rd. CITYISTAT,,P 441�C/r/�/�ot -f5- • ynj 2xP <br />CONTRACTOR (STN er -( NJ IAJC/. PHON 1? -< - d 8 <br />CONTRACTOR ADDRESS / y a y Jt�J / /� L.'T• CITY/STATE/ZIP 64PN dM., N • '? 370 <br />SUBCONTRACTORICONSULTANT PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS ,rCITY/STATE/ZJP <br />LICENSE IXC -57 7 C-61 L D-09 rOther NUMBER 04 70 EXPIRATION DATE 71-31 <br />BILLING PARTY: U OWNER U CONTRACTOR L SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: 17 General Mineral/Coliform Bacteria (4391) C Dibromochloropropane (4392) ID Arsenic (4393) <br />INTENDED USE Domestic/Private D Irrigation/Agricultural D Industrial ❑ Water Quality Monitoring D Soil Sampling/Characterization <br />C Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK XNew Well D Replacement Well D Well Alteration/Modification D Other <br />C Monitoring Well(s) # of wells D Soil Bonng(s) # of borings D Geotechnical tt or borings s <br />Ll Out -Of -Service Well D Out -Of -Service Well Renewal D Cross -Connection Repair AN J <br />❑ New Pum D Pum Replacement 7 Pum Repair C Raise Well CasingEN U/ <br />WELL CONSTRUCTION <br />Drilling Method Mud Rotary C Air Rotary L Auger ❑ Cable Tool C Push Point C Other <br />Proposed Well Depth DO ft Excavation J&09_ in diameter D Open Bottom 7(Gravel Pack/Gravel Size '� in diameter <br />11 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter �._ in Thickness/Gauge/ASTM Sched D Steel 'Plastic D Stainless Steel D Other <br />Grout Seal Depth ft ITNeat Ce nt (94 Ib bag/5-10 gal water) -1Sand Cement sack mix/7 gal water <br />D Bentonite (20% solids) C other <br />Grout Placement Method XPumped C Free Fall ❑ Other F Retardant / Accelerator (name) <br />PEDESTAL Installed By D Driller ❑ Pump Contractor Other <br />IJ Concrete Pedestal LiDimensions: Width It Length ft Thick in L Christy Box L Stove Pipe <br />PUMP i i Submersible i Turbine i Other 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 5AN <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 COMPE SATION LAWS. <br />MINI 48 HOUR ODREQUIRED FOR ,INIEC TIONS -PLEASE CALL (2 09) 9 3-7697 <br />SIGNED TITLE lrll� 41DON7 DATE <br />E <br />� MENr <br />EI QED <br />IR Z 3 2020 <br />4 QU/N <br />�OfvmCO <br />D PAT M NT <br />1q_D. PARTMUSEQ <br />Application Accepted By Dale ate 3 z- <br />Grout Inspection Byl Date 2 C SPECIAL Well Pt.. <br />Pump Inspection By Date D WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth �C' ft <br />COMMENTS C P ii L' Vim' R41 <br />EHD a3-06 6111/2019 <br />WELL /PUMP PERMIT <br />