Laserfiche WebLink
WELL/PUMP PERMIT <br />A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 .6232 (209) 468.3420 <br />NUN-KEFUNDABLE HERMIT WWN <br />Joe ADDRESS 5050 E. MORADA LANE <br />CROSS STREET PLUM AVE APN 08517004 <br />OWNER NAME MARIO DOMINGUEZ <br />OWNER ADDRESS 5050 E MORADA LANE <br />CONTRACTOR GOLDEN STATE IRRIGATION <br />CONTRACTOR ADDRESS 4500E FREMONT <br />SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP. <br />LICENSE i C-57 )(C-61 it D-09 i] Other NUMBER 979833 <br />BILLING PARTY: II OWNER r'�KCONTRACTOR fl SUBCONTRACTOR/CONSULTANT <br />tJIHIKtb 1 YEAR FROM DATE 155U <br />CITY/ZIP STOCKTON 95212 <br />CELSIZE 1ARCE LAND USE APPLICATION # <br />PHONE 209-649-8735 <br />CITY/STATE/ZIP STOCKTON. CALIF 95212 <br />PHONE 209-943-7774 <br />CITYISTATE/ZIP STOCKTON. CALIF 95215 <br />PHONE <br />ExPIRATION DATE 12/31/22 <br />DOMESTIC WELL SAMPLING: �-- General Mineral/Coliform Bacteria (4391) n Dibromochloropropane (4392) -- Arsenic (4393) <br />WENDED USE iXDomestic/Private 11 Irrigation/Agricultural 11 Industrial I I Water Quality Monitoring LI Soil Sampling/Characterization <br />I I Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK 11 New Well 0 Replacement Well ❑ Well Alteration/Modification 0 Other <br />❑ Monitoring Well(s) # of wells 0 Soil Boring(s) p of bodngs n Geotechnical it of borings <br />0 Out -Of -Service Well Il Out -Of -Service Well Renewal 0 Cross -Connection Repair <br />u waw rwnp L-Arurrtp mepiacernem a rump mepair a Kaise vvea easing <br />WELL CONSTRUCTION <br />Drilling Method r Mud Rotary r1 Air Rotary CI Auger I_I Cable Tool I I Push Point Other <br />Proposed Well Depth ft Excavation in diameter I Open Bottom U Gravel Pack/Gravel Size in diameter <br />I I Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schad i Steel i 1 Plastic IStainless Steel ' Other <br />Grout Seal Depth fl I I Neat Cement (94/b bag/5-10 gal water) II Sand Cement sack mix/7 gal water <br />I i Bentonite (20% solids) I I Other <br />Grout Placement Method Ii Pumped n Free Fall I I Other Retardant / Accelerator (name) <br />PEDESTAL Installed By 0 Driller 0 Pump Contractor ❑ Other <br />0 Concrete Pedestal 0DImansions: Width ft Length ft Thick in I I Christy Box 0 Stove Pipe <br />PUMP D(Submersibleu Turbine r1 Other HP 1 Pump Set 140 It Standing Water Level e5 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 CTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKS OM�NLAWS..M VANCE NOTICE REQUIRED SPECTIQNS-LPLEASE CALL (209) 953-7 97SIGNED TITLE -1 I � e(.""� DATE it <br />N <br />RF <br />yMF <br />D CFjV oT <br />NJoFC'?� � -1 11 <br />4TH� p�RT? ` �07-y <br />MFNt <br />DEPARTMENT USE ONLY <br />Application Accepted ByDate %a S Area / 7 Employee ID#Ff4l)l G <br />Grout Inspection By Date 11 SPECIAL Well Permit <br />Pump Inspection By Date I WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE SC Received Check#/ <br />Codes Info B Cas <br />Amount at Permit! Invoice # WeI11D# <br />Remitted Seryice R uest# <br />L OSO <br />7 <br />EMD 43-06 6/112019 CW. � /3 5-2-9 L J,3 <br />WELL !PUMP PERMIT <br />