Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)46"20 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS 1$q i,(- Z-*j% Avs Cr1YlLP ,Efi+/.�% - fw 95324 <br /> CROSS STREET 14 wS3 111.0%, APN 4.OS-616'6%(> PARCEL SIZE!:CEJ-� .AND USE APPLICATION 9 <br /> ate. S <br /> OWNER NAME O CIAO,. t <br /> ^ PHONE �[-7T-7aoq <br /> OWNER ADDRESS 1 50so S . 1- rPky •'`^. CITY/STATE21P 'Std/.-I C. 7SNjD <br /> CONTRACTOR tA& t(jIf pc-1111n5 :r.c. PHONE S'Z2-/120 <br /> CONTRACTOR ADDRESS I I 1 A16-t/S CITY/STATEIZM_Mrd*q�r r d*S h, e.'i -IT 3 5*7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CrTY/STATFJDP t <br /> LICENSE )f C-57 D C$1 0 D-09 0 Other NUMBER jaf gG Z2 EXPIRATION DATE <br /> DOMESTIC WELL SAMPUNG:p General MinerallColiforrn Bacteria(4391) 1 Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTEHDED USE )(Domestidplivete 0 Irrigation/Agricultural 0 Industrial D Water Quality Monitoring 0 Soil Sampling/Characterization <br /> D Public Water System <br /> If different from Owner: Water System Nuns Contac!Name or Phone Number <br /> TYPE OF WORN New Well XReplacemenl Well 0 Well Allerabon/Moditkation -q Other <br /> G Monitoring Well(s) k of wells 0 Soil Borings) s of bortps D Geotechnical s ofbori ga <br /> D Out-Of-Service Well 0 Oul-Of-Service Well Renewal D Cross-Connection Repair <br /> D New Pump 0 Pump Replacement 0 Pump Repair D Raise Wen Casing <br /> WELL CONSTRUCTKNI <br /> Drilling Method%I�lud Rotary A D Air Rotary 0 Auger 0 Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depth 24n¢_ft Excavation. /-I- " in diameter ❑Open Bottom [XGravel Paek/Gravel Size in diameter <br /> D Conductor Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 10 In Thickness/Gauge/ASTM Sched Z A6 ❑Steel Mastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth 2d0 R ❑Neat Cement(94/b baW5-10 gel water) 0 Sand Cement sack mixf7 gal water <br /> ,l(Bentonite(20%solids) D Other <br /> Grout Placement Method Pumped 0 Free Fan ❑Other ❑Retardant/Accelerator(name) <br /> PEDeaTw Installed By 0 Driller 0 Pump Contractor 0 Other <br /> 0 Concrete Pedestal❑Dlmsnsiors:Wkf01 1t Length it Thick in D Christy Box 0 Stove Pipe <br /> PUMP 0 Submersible Turbine 0 Other HP Pump Set it Standing Water Level <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 M O R ADVANCE NOT REQUIRED FOR INSPE TION -PLEASE CALL(209)953-7697 <br /> SIGNED TR-E DATEawl r <br /> CEFNT <br /> IVES <br /> P 15 2021 <br /> QU <br /> q ONMENOUNTY <br /> EpqR T MFNT <br /> #--------- — <br /> DEPARTMENT USE ONLY ll ( ( <br /> Application Accepted ByDate <br /> Area r I / Employee IDk (� <br /> Grout Inspection By Date \ ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring lospeoon By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC FlseNwd Chsckll// Amount le Pis It/ Invoice k Well IDk <br /> Codas Into h Remitted nice tNa i <br /> 5 3 ti <br /> EHD 43-09 4/01!16 0 <br /> 2—G/ / WELL RUMP PERA9T <br />