Laserfiche WebLink
WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />PERMIT <br />� r <br />JOB ADDRESS <br />'�n(�SL�1 l %�'r �V - ry�� <br />CROSS STREETS V 14t-t/(VV I RLU�I� P�NJ101-10-9- <br />'`,01 Vad-��C� <br />OWNER NAME �✓(�/�Gt V�=�1� Ll �v[/F �{i/LY)Jy <br />OWNER ADDRESS <br />CONTRACTORI� l�.1 t•l Ly\Lu( <br />CONTRACTOR ADDRESS p Rn <br />yl,`7 <br />SUBCONTRACTOR/CONSULTANT 11, A-) <br />tAVIKtb l YEAR FROM DATE ISSUED <br />PARCEL SIZELft �LAND USE APPLICATION # <br />PHONE <br />CITY/STATEIZIP <br />1,MPHONE,,�, I�// <br />CITYISTATE/ZIP �M J�{((J�i/i�V R 1J7? <br />PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITYISTATE/ZIP <br />LICENSE C-57 C-61 D-09 Other NUMBERI-WfQal'-� EXPIRATION DATE <br />BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED 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 />Monitoring Well(s) # of wells Soil Boring(s) # of borings Geotechnical <br />Out -Of -Service Well Out -Of -Service Well Renewal Cross -Connection Repair <br /># of borings <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 It <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 lb bagl5-10 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 />Concrete Pedestal Dimensions: Width / ft Length It Thick in Christy Box Stove Pipe <br />PUMP )(Submersible Turbine Other HP Pump Set ft Standing Water Level It <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 />DEPARTMENT USE 7NLY l� <br />Application Accepted By ���"/moi Date ar Area / �C Employee ID# ER <br />Grout Inspection By Date SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspectipp ByDate Tom— Constructed Well Depth It <br />COMMENTS IjClr <br />„6t pQwt-r j^jP0C <br />3 <br />HD43-06 8/11!2019 I r / / L� / �J -7 WELL)PUMP PERMIT <br />VENT <br />D <br />2421 <br />AUNTY <br />MFNT <br />• �►��r.-ter.; ,��E <br />�MMEWI <br />HD43-06 8/11!2019 I r / / L� / �J -7 WELL)PUMP PERMIT <br />VENT <br />D <br />2421 <br />AUNTY <br />MFNT <br />