Laserfiche WebLink
WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT www_cianv_orn1Phr1l — EXPIRES 'I YFAR FRnM nATF ISSIIFn <br />JOB ADDRESS CITY �,(/� a (� <br />CROSS S/tTy/J'7z T ' ` APN a q a sa 3 LIPARCEL SIZE 6 ,7C9 LAND USE /A'`P��PLICATION # ,{ �% <br />OWNER NAMC �- r 14 1 " J 0 cri-1 3-��y-`�A PHONE ✓/j � t4 ` <br />OWNER ADDRESS 793 �jJ/� I�j I VA 11 r 2_20 Crrl/STATE/LJP a " `�� .? . ?� <br />CONTRACTOR/7 ell ✓ �-+� C—An I if PHONE r U lJ <br />La <br />CONTRACTOR ADDRESS) 9, ! VlU IT% P <br />J <br />SUBCONTRACTOR/CONSULTI VI t/P <br />HONE ffr <br />rV <br />SUBCONTRACTORICONSULADDRESS C/STA <br />61 D-09 OtheW/O <br />LICENSC-57 r <br />ExPIRA TE <br />BILLING PARTY: OWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br />DOMESTIC WE L AMPUNG: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED USE DOmeStiC/PriVate nigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />It 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 # of borings <br />Out -Of -Service Well,Out-Of-Service Well Renewal Cross -Connection Repair <br />New Pump , Pump Re lacemen Pumpfevir I Raise Wel Casin <br />WELL CONSTRUCTION e <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 ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 Ib bag/5-10 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 It Len th ft Thick in Christy Box Stove Pipe <br />PUMP Submersible Turbine Other HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH 5AN <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 ONLY <br />Application Accepted By �L Date a ) <br />Grout Inspection By Date <br />Pump Inspection By to <br />Soil Boring nspe io y Date _ <br />COMMENTS t q(2_� <br />%, � I t ('Ll, — V. q Q� <br />Area c 9(1 Employee ID# <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth It <br />D <br />0 <br />m <br />rn <br />01 <br />EHO 43-06 6/11/2019 <br />WELL /PUMP PERMIT <br />V CNTY <br />FN7U <br />R rMENT <br />.. ... <br />Service # <br />• p//:�J� �� E�iTr�rlrl►. Ii!r1►MY.�:Il�1� <br />EHO 43-06 6/11/2019 <br />WELL /PUMP PERMIT <br />V CNTY <br />FN7U <br />R rMENT <br />