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-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> TN <br /> JOB ADDRESS •� 41 <br /> CITY/ZIP j1'1 J m <br /> //yy//�� (� r L}- y� D <br /> CROSS STREET ��(} L!//�.-/ 1 �•'/ APN t/ 1 ` �V� PARCEL SIZE LAND USE�A1PP`LICATIONN j#� A <br /> OWNER NAME `�yfc., �r� /A PHONE Z J�- �^'�l Cn <br /> OWNER ADDRESS 1 � CITY/STATE/ZIP <br /> CONTRACTOR "4v _/ PHONE <br /> WJ� <br /> CONTRACTOR ADDRESS ICITY/STATE/ZIP <br /> SUBCONTRACTOR/CONSULTANT �/Wz PHONE 7i��r��/!!�Ffy►*✓y/�/y'/`��>�[}+>�+� <br /> � •� <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE �C-57 C_I C-61 1,1D-09 El Other NUMBER3,7735r EXPIRATION DATE <br /> BILLING PARTY: OWNER ONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE Domestic/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 /> Ll Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings I I Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑I Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 4�Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth7:3l ft Excavation /-I— 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 Sched7_3c�' ❑ Steel Plastic ❑ Stainless Steel it Other <br /> Grout Seal Depth /Do ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ,>YSand Cement /C�r sack mix/7 gal water <br /> ❑ Bentonite(20%solids) 11 Other <br /> Grout Placement Method Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ❑ Pump Contractor - Other F4 <br /> I Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine 11 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 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. <br /> MINI 4 HO�j�JJR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL(209)953-7697' / <br /> SIGNED I/� -�T�'P� TITLE O6.�/V6/- DATEL�� y <br /> 1711 <br /> TY <br /> NVIRCINN E T <br /> NT <br /> U r DEP RTM ENT USE ONLY <br /> Application Accepted By 1A Date �bIZ Area Employee ID# 4; &j <br /> Grout Inspection By (h, `Cc, rYU Date S �i I u \ SPECIAL Well Permit <br /> Pump Inspection By �( Y`_,�o 15�,-�;L �, ;/l Date '��q(y Z1 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS L. � 4 rj Ct/ LC �)L b`,�r�Gl1Aa <br /> PE SC Receive Check#/ Amount Date Permit/ Invoice# Well ID# <br /> COCIDS Info Cqsh Remitt Service Re uest# <br /> 4} -23-Z N P LTN I of <br /> 23 2OP 0 <br /> EHD4316 6/11/2019 WELL/PUMP PERMIT <br />