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.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> Ic—J <br /> JOB ADDRESS —2— O J J C. CITY/ZIP n'In m <br /> ?� -7 D <br /> CROSS STREET C Jam+ APN V� / PARCEL SIZE LAND USE APPLICATION# o <br /> rn <br /> OWNER NAME �J�J/f�j 1�p / 7�!b PHONE ` L tyi� <br /> OWNER ADDRESS �t 'l"� j CITY/STATE/ZIP <br /> CONTRACTOR �^�• l/�✓ ' PHONE.—,,/ � <br /> CONTRACTOR ADDRESS ! 60'4-��/1/��• n,, ,l► CITY/STATE/ZIP e/C/6��i At <br /> SUBCONTRACTOR/CONSULTANT �C. �1! XD :J rKaz V /' PHONE Za <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP f <br /> LICENSE _$eC-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: OWNER .XCONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:X General 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 XNew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical a of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> 20 qew Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method�Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool LI Push Point ❑ Other <br /> Proposed Well Depth o ft Excavation IL in diameter ❑ Open Bottom ravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter 6' in Thickness/Gauge/ASTM Sched ❑ Steel <Plastic ❑ Stainle s Steel ❑ Other <br /> Grout Seal Dep[hT(? c"3 ft 11 Neat Cement(941b bag/5-10 gal water) /Sand Cement 1 sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method,-�14Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller ❑ Pump Contractor�/ ❑ Other <br /> 1-1ConcretePedestal❑Dimensions:Width 7 ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Zubmersiblell Turbine ❑ Other 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. 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 /> 77Z <br /> ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL (209) 953-7/697� / <br /> SIGNED TITLE M4_1��. DATE L `/ <br /> DO <br /> T <br /> D <br /> I <br /> SN J DA1NTY <br /> N IR DN MENTAL <br /> NT <br /> DEPARTMENT USE 1ONLY U t <br /> Application Accepted By `I L� Date � 1 1 <br /> d h Area I �G/ Employee ID#FA <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS /VP.t�J WP) SSP`` �� b�\e.a 5,r—& <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info EW Remitted I Service Request# <br /> H390 PSo 4 Is'l�? [ 2 <br /> H34, j 8a 9'�i 5 rtq <br /> 39 1 J5c7 ll ► J <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />