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-11F-FUNDABLE <br />VERMIT www.sjgov.orgiena tXPIRE-51 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS ! ,j41L r, CITY/ZIP `0o/ 1 <br />CROSS STREET r -J - AS PN/ 02 7i)2 0 16 PARCEL SIZE I, L1 7—LAND USE APPLICATION <br /># <br />OWNER NAME �/I C C ,Ako PHONE -7! -2 - 45'0-K / <br />OWNER ADDRESS ;::A;"& CITY/STATE/ZIP <br />CONTRACTOR'S �/� / v-` �/��% ^ ► , PHONE <br />CONTRACTOR ADDRESS J ✓� 7�� ' CITY/STATE/ZIP <br />SUBCONTRACTOR/CONSULTANT IG CS + 77� PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br />LICENSE XC -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER '1 'i 73t? r EXPIRATION DATE "✓i7 <br />BILLING PARTY: OWNER AONTRACTOR SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING:AGeneral Mineral/Coliform Bacteria (4391)( Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTENDED USE >< Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ Public Water System <br />If different from Owner: Water System Name Contact Name or Phone Number <br />TYPE OF WORK >4ew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Well(s) # of wells ❑ Soil Boring(s) # of borings ❑ Geotechnical <br />❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal ❑ Cross -Connection Repair <br />ew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other SAN .JOAQUIN <br />Proposed Well Depth njO ft Excavation 11 in diameter ❑ Open Bottom ..Gravel Pack/GravelsA NME A>'amr <br />11 Conductor Casing in diameter / Conductor Casing Depth ft LT>,ITMENT <br />Well Casing Diameter -16' in Thickness/Gauge/ASTM Sched -dim ❑ Steel AC'Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth^/L� ft ❑ Neat Cement (94 lb bag15-10 gal water) Sand Cement ��i�% 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 �_ ft Length ft Thick in ❑ Christy Box ❑Stove Pipe <br />PUMP 5.%ubmersible❑ Turbine ❑ Other HP —2,- Pump Set ft Standing Water Level 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 AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />MINIMUM <br />M48,H'O/UR AA VANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697) <br />SIGNED Ji._/�L!/_,y-. TITLE o- .[//tai DATE <br />UtYAK I Mt:N I UJC U N L T <br />Application Accepted By Date R l -r 'o -� <br />Grout inspection By Date Z (4N7i02Z <br />Pump Inspection By ��m Date <br />Soil Boring Inspection By <br />COMMENTS <br />Date <br />Area `r' C' Employee ID# D A <br />❑ SPECIAL Well Permit <br />❑ WAIVER Received <br />Constructed Well Depth <br />T <br />-i <br />m <br />D <br />0 <br />0 <br />M <br />M <br />N <br />V1 <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />�i'�/.•�l�E�RMI <br />► ! 'rte <br />SO <br />ME <br />EHD 43-06 6/11/2019 WELL /PUMP PERMIT <br />