Laserfiche WebLink
0 <br />Y <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205.6232 (209) 468-3420 <br />NON-REFUNDABLE PERMIT WWW.Si9oy.ara/ehd PYDill -1 v-- ­n.. <br />`-� c c� (� ` cnrc rrcvm uw I t ISSUEC <br />JOB ADDRESS 1 T� U 1 ) (' S �A V\C" 1 ( A, (� <br />_ I t9 � T <br />CROSS STREET� Qr -Q �L APN 571 $ D S CITY/ZJP L <br />_ PARCEL S�ELAND USE <br />�AjPPLICATION# <br />OWNER NAME ) G M JLdI � 10 n !� PHONE D ' ZO� `'"6 p --Z-9 <br />OWNER ADDRESS p �I I O y1 CITY/STATE/ZIP ,(fl[A+ +.` 53' 3� <br />CONTRACTOR S ✓' e. ' (\ PHONE 'ZO-1 -.J'vj--1 —W�u7 <br />CONTRACTOR ADDRESS v 1 uL, l CITY/STATEMP_ 1 \Q 1- O Ci1'0 h-2 6 <br />SUBCONTRACTOWCONSULTANT —r <br />—PHONE <br />SUBCONTRACTOR/CONSULTANT ADDRESS - CITY/STATE(ZIP <br />LICENSE C-67 C-61 D-09 Other. <br />BILLING PARTY: OWNER _ '`�1P <br />NUMBER -1-7 6 G6 0 EXPIRATION DATE <br />SUBCONTRACTORICONSULTANT <br />DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />INTENDED UsE Domestic/Pnv Irrigation/Agricultural ndustr al Water Quality Monitor ng Soil Sampling/Characterization <br />PU ater System <br />If different from Owner. Water System Name <br />Contact Name or Phone Number <br />r. a.r vvuKK 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 />t ep )(Pum Replacement Pum Repair Raise Well Casing <br />--OSTWECN� <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 n diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter n Thidcness/Gauge/ASTM Sched <br />Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 Ib bagl5-10 gal water) Sand Cement <br />Bentonite (20% solids) Other sack mix77 gal water <br />Grout Placement Method Pumped Free Fall Other <br />Retardant /Accelerator (name) <br />PED TAIL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width ft Lengt it Thick in Christy BoxStove Pipe <br />PUMP Submersible Turbine Other <br />HP 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE Rnean <br />7� ut_FART NT U E N L Y <br />Application Accepted By �_/ -- ate <br />Grout Inspection By 4�D:'IePUmp Inspection By <br />Soil Boring Inspection By <br />}� Date <br />COMMENTS D O r I.' :M P ✓1 r'b A 1, �, o c z--J--r 1— <br />Area S Employee IN A <br />SPECIAL Well Permit <br />WAIVER Received <br />EHD 0.3-06 6/11/2019 <br />_o <br />g <br />e <br />X <br />PAYMENT <br />RECEIVED <br />SEP 2 2 2022 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />IJEALTH DEPARTMENT <br />