WP0042411 - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMIT g-� � SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENYE - STOCKTON CA 95205 -6232 (209) 468-3420 NUN-KEFUND E ERMIT -�> DEPARTMENT USE ONLY Fes" Date (`7 MonitoringWell(s) #of wells SoilBonng(s) #of borings Geotechnical #of borings Grout Inspection By sjgov.orgt1na tAVIKCJ I TEAR FROM DATE ISSUED ADDRESS New Pum Pum Re laceme �Dm Re Raise fell jasog Date � to �-1- 2 L 16LJOB CITY/LP �'� CROSS STREET OWNER NAME `%� OWNER ADDRES T3 0 n `y T(4 ✓ ✓ A C' - OA PARCEL SIZE I LANDU E APPLICATION # P PHO /� CITYIST�1 ,o 2 � R/ CONTRACTOR v JT�/ �) r ✓ PHON `� ✓`' CONTRACTOR ADDRESS l / J Lt L L 14 PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level It CITYISTATEP p 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN SUBCONTRACTORICONSULTANT 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. _ SUBCONTRACTORICONS�UULL/T�!_1T ADDRESSI-A LICENSE C-57 C:-61 D-09 Other_ TY/STATE/ZIP r V NUMBER '1-7`� �✓ EXPIRATION DAT !/J BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT )OMESTIC WEL !e PLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) 4TENDED USE omestic/Private Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization Public Water System If different from O—r. Water System Name Contact Name or Phone Number y m g fn m L"I L v y TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other -�> DEPARTMENT USE ONLY Fes" Date (`7 MonitoringWell(s) #of wells SoilBonng(s) #of borings Geotechnical #of borings Grout Inspection By Out -Of -Service WellOf-Service Well Renewal Cross -Connection Repair SPECIAL Well Permit New Pum Pum Re laceme �Dm Re Raise fell jasog Date � to �-1- 2 L _ WELL CONSTRUCTION C( LR Soil Boring Inspection By Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other Constructed Well Depth It Proposed Well Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 gal water) Sand Cement sack mixl7 gal water r Bentonite (20% solids) Other Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) PEDESTAL Installed By Driller Pump Contractor Other Concrete Pedestal Dimensions: Width ft Len h ft Thick in Christy Box Stove Pipe PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level It 1 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. E REQUIRED FQf�1�JS- PE,C� ,NNS/-�PLEASE CALL (209) 3-7697 r V[ / /_M;MF!:=1 SIGN] TITLE ,�C I Y IY�(/f ) DATE N lal�ttal�lalalal�talalattatt�lala tt�lalat�w�t�l�ta�all�ll�t� tta�ll�ll�ll�ll� Il�t�lll� II�II�II� r RFgy�i 411010 FO �01oi,,. ?�?I Application Accepted By -�> DEPARTMENT USE ONLY Fes" Date (`7 N / Area `� CI Employee ID# h `17 Grout Inspection By Date SPECIAL Well Permit Pump Inspection By Date � to �-1- 2 L WAIVER Received Soil Boring Inspection By Date Constructed Well Depth It COMMENTS EHD 4x-06 6/11/2019 WELL /PUMP PERMIT TMFNT ffm�"%AA .: E ��n �n r�rl�»�►�� EHD 4x-06 6/11/2019 WELL /PUMP PERMIT TMFNT