Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)488-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> rn <br /> JOB ADDRESS CtTYZP <br /> D <br /> CROSS STREET APN 2tAPARCEL S¢E 'e LAND USE APPLICAT�I/Or,IN• a <br /> OWNER NAME ' 'NUA'1/''PHONE /��{� ' t/y�'10rv—J�/7J, <br /> OWNER ADDRESS0 OD � CITY/STATEMP I•I V4 n V\- (V 1 q ✓ ✓9 7 <br /> CONTRACTOR IV PHONE �] <br /> CONTRACTOR ADORE. CtTY/STATEIZIP o <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP ^� <br /> LICENSE C-57 0 C$1 0 D-09 0 Other NUMBER ExPIRATION DATE / V' <br /> DOMESTIC WELL SAMPuw:0 General Mineral/Coliform Bacteria(4391)L)Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE XDomesfidPrivate 0 Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization <br /> r Public Water System <br /> If different tram Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well ❑Replacement Well 0 Well Alteration/Modification 0 Other <br /> C Monitoring Wells) S of wells 0 Soil Boring(s) $0 b01hVil 0 Geotechnical e of twrvgs <br /> 0 Out-Of-Service Well C Out-Of-Service Well Renewal 0 Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement C Pump Repair 0 Raise Well Casing <br /> WELL CON3TRUCTION <br /> Drilling MathodXMud Rota C Air Rotary C Auger 0 Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth ft Excavation��in diameter Open Bottom t�Gravel Pack/Gravel Si;* in diameter <br /> C Conduct Casing in diameter / Conduct asing Depth ++ ft <br /> Well Casing Diameter. in Thlckness/Gauge/ASTM Sched � 0 Steel Plastic C Stainless Steel ❑Other <br /> Grout Seal Depth It 0 Neat Cement(941b bag/5-10 gal water) Sand Cement sack misfit gal water <br /> )kPentonite(20%solids) ❑Other <br /> Grout Placement Method 4,P.mpd 0 Free Fall 0 Other 0 Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal CDlmensions:Width It Length It Thick In 0 Christy Box 0 Stove Pipe <br /> PUMP 0 Submersible Turbine ❑Other HP Pump Set It Standing Water Level tt <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 /> MI UM UR DVANCE NOTICE REQUIRED FOR INSPECTI NS-PLEASE CALL(209)9953-76(917 <br /> SIGNED TITLE DATE 1� ZW•�� <br /> 4 <br /> E MFNT <br /> l�E� <br /> • 2 2021 <br /> O FNM C00ty <br /> 7. <br /> EPq IV r'4 <br /> TMENT <br /> DEPARTMENT USE N L Y /l <br /> Application Accepted By ! Date 7 Area S �r Employee ID# ACV <br /> Grout Inspection By ate L 1, Z OZ ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WANER Received <br /> Soli Boring Inspection By Date CginsbruclIN1,W911 Depth ft <br /> CO MENTS �11rt IY�L':lei /\ ��Iyl�f L,:V!D L< V y41)y tS rPc,11'wd <br /> PE SC Received Check// Amount Data Permit/ Invoice t Well IDS <br /> Info B C h Remitted Service Request t <br /> W3 le 20 ZA&L5 ZON 2 <br /> -L%-144 <br /> 7 5 WED 09 13�15 <br /> EHD 4S-0e 8gtna WELL/PUMP PERMIT <br /> lZ9 0l I zoz <br />