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 /> LA <br /> ADDRESS � yV��G\\ �Ct CITY/ZIP � CJL r <br /> Y G' . . l P' m <br /> ur' D <br /> CROSS STREET M^ue 1r\hut ��\�I C APN PARCEL SIZE LAND USE APPLICATION# M <br /> In <br /> OWNER NAME Noe\ \�\ ��Y�h�2 PHONE N <br /> OWNER ADDRESS !)-7—`SQ �W`YY(A\(1�. \—o0.� CITY/STATE/ZIP A`(G\CJL <br /> CONTRACTOR WA Vv� UWtiQiY PHONE .J 1 <br /> CONTRACTOR ADDRESS CITY/STATE/ZJP <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE C-57 6 D-09 Other NUMBER EXPIRATION DATE <br /> BILLING PARTY: WNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE omestic/Private Irrigation/Agricultural 'Industrial Water Quality Monitoring i Soil Sampling/Characterization <br /> blic Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number 3 <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other r <br /> Monitoring Well(s) #of wells Soil Boring(s) #of borings Geotechnical #of borings <br /> Put-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement -Pump Repair Raise Well Casing <br /> WELL CONSTRUC& r <br /> Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other n <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/b bag/5-10 gal water) Sand Cement sack mixf7 gal water Vj <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 L ft T ' Christy Box S ipe <br /> oe"PUMP Submersible Turbine Other P P m Set Standing Water Lev I <br /> I HEREBY CER FY THAT I HAVE PREPARED THIS APPLICAT THEW L BE DONE IN ACCORDAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS r�+ <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL l <br /> WORKERS COMPENSATION LAWS. <br /> INI U O6R ADVANCE 209,1953-7697 <br /> NSIGNED TITLE � � j&4ZATE d • <br /> R gyMF <br /> FcF���r <br /> ®FC FO <br /> 0 <br /> ' i ON NCD 019 <br /> y�F,oM RUIV14- <br /> MFHT <br /> A�2 MENT US O LY <br /> Application Accepted By ate ( Area ;; Employee <br /> Grout Inspection By Date PECIAL Well Penult <br /> Pump Inspection By Date i WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Checkk Amount D to Permit/ Invoice# Well ID# <br /> o es Info Cash Remitted Service Re uest# <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />