Laserfiche WebLink
WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 -6232 (209) 468-3420 <br />NUN-KEFUNDABLE PEE�R/MI(T� <br />WWW.Sjgoy.Orq/ehd <br />EXPIRES 1 YEAR FROM DATE ISSUEC <br />JOB ADDRESS y(J I `-1 Q <br />/ <br />r� g iii j , -PTCC. <br />^ <br />)-- c .1. CHYIZ'I}'P <br />( <br />7�\ C6,tn Q ) �+ Ci �l� �•X <br />ppN <br />CROSSSTREETCC' 1 tlil- Kt <br />� APN 00540001 <br />PARCEL SIZE Qf<. LAND USE APPLICATIONN/ <br />��tt /i <br />OWNER NAME "1 r"1 L <br />C,,n Z <br />EHD 43-06 6/11/2018 <br /># r <br />PHONE G <br />OWNER ADDRESS <br />CITY/STATE/LP <br />CONTRACTOR1 f e! <br />PHONE 3(, c) -2 7 / 1 <br />CONTRACTOR ADDRESSy U• Ili) <br />'l cel <br />j j C /STAT%% <br />} <br />Go, 1 �- I C <br />SUBCONTRACTOR/CONSULTANT <br />- <br />PHONE <br />SUBCONTRACTORICONSULTANT ADDRESS _ <br />LICENSE )(C-57 ❑ C-61 ❑ D-09 <br />BILLING PARTY: ❑ OWNER <br />CITYISTATE/ZIP <br />❑ Other NUMBER d , b 3 <br />,CONTRACTOR 0 SUBCONTRACTOR/CONSULTANT <br />ExPIRATION DATE / J �? U <br />DOMEsnc WELL SAMPLING:X General Mineral/Coliform Bacteria (4391) )YDibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE A Domestic(Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br />❑ Public Water System <br />v�/��If��different from Owner: Water System Name � Contact Name or Phone Number <br />TYPE OF WORK XJ New Well ❑ Reolaeement Well rl Wall Alteratinn/Mndifir Linn n "hn, <br />0 Monitoring Well(s) # of wells ❑ Soil Boring(s) a of b°nngs 0 Geotechnical # of borings <br />❑ Out -Of -Service Well D Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />Drilling Method A Mud Rotary 0 Air Rotary ❑ Auger 0 Cable Tool ❑ Push Point D Other <br />Proposed Well Depth :2,41i ft Excavation 'l ' in diameter ❑ Open Bottom X Gravel Pack/Gravel Size!_ in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched (Y^ ❑ Steel Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth )(`0 ft ❑ Neat Cement (94 lb bag/5-10 gal wate j Sand Cement in • :7� sack mixll 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 D Other <br />1g Concrete Pedestal ❑Dimensions: Width _ -ft Length it Thick in ❑Christy Box n Stove Pipe <br />PUMP ;L4 Submersible ❑ Turbine ❑ Other HP 3 Pump Set q 5i ft Standing Water Level Ci (; 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 />isf:9W1'13d)� eo+ (10-1 "a faI349ANC;E N1017 -CE REQUIRED rOR INSPECTIONS-1-1!.tEASE CALL (209) /35'a.%Cv7 <br />SIGNED/.,/�'r �CL�✓)-?'-1✓� TITLE \l I CC 2 -`fS i rl e 04DATE 4� / i 5 I., <br />y oNM�C0 pjV <br />pEN R K <br />DEPARTMENT USE ONLY <br />Application Accepted By Cesar Ruvalcab Date 4/20/2020 Area 4/95 Employee ID# SK <br />Grout Inspection By Date S// 3 C'f' ❑ SPECIAL Well Permit <br />Pump Inspection By Date ❑ WAIVER Received <br />Soil Boring Inspection By Date Constructed Well Depth ft <br />COMMENTS <br />PE Sc Received <br />Check#/ Amount Date Permtf/ <br />Codes Info B <br />Cash. Remitted Service Re uest# Invoice # Well ID# <br />4391 <br />�► $145 <br />4392 <br />$70 <br />4366 180 <br />$420 WP0040740 <br />4380 <br />$152 WP0040 41 <br />EHD 43-06 6/11/2018 <br />J n <br />WELL /PUMP PERMIT <br />/ ` ^ 1/ t3 <br />