Laserfiche WebLink
DEPARTMENT USE ONLY <br /> Date 7/ Va 1 I Area /'"I Employee ID* D A Date <br /> Dale rr,( <br />Date <br />Application Accepted By <br />Grout Inspection By <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />Checkt/ Amount <br />Cash Remitted <br />ifie/CF-PI I f7? I 93in <br />PE Sc <br />Codes Info <br />Receive <br />U Date Permi I S ice Request # n I Invoice # Well !al <br />21_ MO0 ,2 '610'11 <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />NON-REFUNDABLTMIT <br />JOB ADDRESS <br />INELL/PUMP PERMIT <br />1868 EAST HAZELTON AVENUE <br />ov.orgiehd <br />CITY/21P <br />1 ,7 LAND USE APPUC Tlo # <br />PHoN :6S32/001y 311S 1139/1) <br />ckhrh 01_95)t.5 <br />APN <br />/A_ . 4 On <br />Coy/STATE/ZIP .7e7ra.M71.A.-„ArimmIr <br />CROSS STREET <br />l <br />OWNER NAME <br />OWNER ADDRESS <br />CONTRACTOR <br />CONTRACTOR ADDRESS <br />SUBCONTRACTOR/CONSULTANT <br />PARCEL SIZE <br />CITY/STATE/ZIP <br />PHON <br />PAYMENT <br />ECEIVED <br />AUG 0 3 2021 <br />N JOAQUIN COUNTY <br />ENVIRONMENTAL <br />;1 TH DEPARTMENT <br />11711111111111051111111111111•1111111111111111111111.111111111111111111111111•1111111111111111111111111111111 <br />"_. Concrete Pedestal =Dimensions: Width <br />_f t Le Othern g th <br /> <br />.iiia <br /> ft Thick in = Christy Box = Stove Pipe 1 IPump Submersible _ Turbine 7 Other HP I.) Pump Set icillo, Standing Water Level a, 4 ft I I HEREBY CER FY THAT I HAVE <br />PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND <br />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 LAW <br />SIGNED iY' <br />J) I ".' V2 LjEt. NOTICE REQUIRED FOR 111SPECTIONS - PLEASE CALL (209) 950-76,?7 <br />; , <br />TITLE ,./1Y2el. DATE <br />1 I I <br />PEDESTAL <br />WELL CONSTRUCTION <br />GrIttIng Method Mud Rotary _ Air Rotary _ Auger Cable Tool _ Push Point . Other Proposed Well Depth ft Excavation in diameter - Open Bottom IT Gravel Pack/Gravel Size in diameter <br /> <br />- Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel IT Plastic T Stainless Steel Grout Seal Depth ft - Neat Cement (94 lb bag/5-10 gal water) Sand Cement Bentonite (20% solids) Other <br />Grout Placement Method - Pumped IT Free Fall = Other <br />TYPE OF WORK - New Well Replacement Well - Well Alteration/Modification - Other Monitoring Well(s) # of wells Soil Boring(s) et of bofings _ Geotechnical <br />IT CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />LICENSE -57 <br />SILUNG <br />SUBCONTRACT /CONSULTANT ADDRESS i‘fi <br />DOMESTIC WELL SAMPLING: _. General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) _ Arsenic (4393) <br />NTENDED USE XDomestic/private Irrigation/Agricultural Industrial n Water Quality M ri <br />Installed By - Ddller = Pump Contractor <br />ell Out-Of-Service i ._ Out-Of-Service Well Renewal _ Cross-Connection Repair IT New Pump Pump Replacement = Pump Repair = Raise Well Casing <br />Public Water System <br />If different from Owner <br />IT C-61 IT 0-09 J Other <br />OWNER <br />NUMBER <br />--Retardant / Accelerator (name) <br />CAI /STATE/ZIP <br />&af <br />onit o ng T Soil Sampling/Characterization <br />Contact Name or Phone Number <br />EXPIRATION DATE <br />PHONE <br />= Other <br /> sack mix/7 gal water <br /># of borings <br />S-rocicroN CA 95205 -6232 (209)468-3420 <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />( <br />Water System Name