Laserfiche WebLink
f-� -� 0 <br />,w► WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-RFFttNnARt F PFRMIT www-wianv-nra/phd l 1 EXPIRES 1 YmR FRnM nATF Issl IFn <br />Joe ADDRESS j <br />G C p Cll I G1 . <br />CROSS STREET "' 0 P O `� �y/�� APN - O s 11' d �l/�� �/�l P�A/R�CE�y/' F s- D SE AP LIrGJ`ATION # <br />OWNER NAME 1 1 ,J ` • & t � "' E"' <br />" <br />OWNERADDRESS Y'fWCI TEIYJP If <br />CONTRACTOR , ` (`�,r�' PH� <br />CONTRACTOR All _ �/ J J /L4 � V/ TYISTA /A� �r <br />SUBCONTRAIV <br />CTOR/CONSULTANT _/ PHONE A <br />SUBCONTRACTORICONUL DDRESS 1\ CITY/STA <br />LICENSE C-57 AlC-60-09 Othe NUMAE''j (P(DExPIRATION DATt 3 U d. <br />BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br />DOMESTIC WE Sir <br />PILING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USEDomestic/Private 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 />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />Monitoring Well(s) # of wells Soil Bohng(s) # of borings Geotechnical # of borings <br />Out -Of -Se ell Out -Of -Service Well Renewal Cross -Connection Repair <br />New Pum Pump Replacement Pump Repair Raise Well Casing <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 Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mix/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 />oncrete Pedestal Dimensions: Width ft Length ft Thick in Christy Box Stove ipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water Le ft n� <br />IHEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <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 COMPENSATION LAWS. c <br />MI n 48 H AD E�NOTICE REQUIRED F INSP/EJC�TIO/N�S�- PLEASE CALL (209103-7697V^ 11 <br />SIGNED r TITLE DATE \t1" <br />M <br />g <br />V <br />Q— <br />DEPARTMENT USE ONLY <br />Application Accepted By �-- /�-2-Z- Date 9 O 1 <br />Grout Inspection By Date <br />Pump Inspection By Date ZZ. 2-CrL"l <br />Soil Boring Inspection By Date <br />COMMENTS <br />A�THRF gRT�NTY <br />Area r Employee ID# <br />SPECIAL Well Permit T <br />WAIVER Received <br />Constructed Well Depth ft <br />EHD43-06 6/11/2019 <br />WELL /PUMP PERMIT <br />�.. <br />� <br />+ • I!/iL�� _ l�Z7L'ri�l IR1I�I�ILY��' �� I <br />EHD43-06 6/11/2019 <br />WELL /PUMP PERMIT <br />