Laserfiche WebLink
WELL/PUMP PERMIT <br /> ` SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(209)468-3420 <br /> NON-REFUNDABLE PERMIT-1 CALL 2/09 953-7.6197 FOR INSPECTIONS EXPIRES YEAR FROM DATE ISSUED <br /> . <br /> JOB ADDRESS ^ N - A J `� CITY/ZIP / 485"rtZA m <br /> D <br /> CROSS STREET Ut4 1�d P- ��DA•,,, JAPN ZZAI 1100 D� PARCEL SIZE `LI I•2- LAND USE <br /> APPLIIC}ATIONN# <br /> L.Iq o <br /> OWNERNAME PIPKN�KRt �N7'-' .1 I�Q2Yu�2S LL-L �JPHONE,,I�M� t� 4L f��� vi <br /> OWNER ADDRESS • '�• v 1 1 O CITY/STATE/ZIP /n 4 L)I�Nr 6A r ✓ <br /> CONTRACTOR V j w P&4L4-1#,J(A � 4(- �e PHONE -71 <br /> CONTRACTOR ADD'RE'SS 11 *33R/�- 1C,.K+���sr 1^�- CITY/STATE/ZIP `+ q'10- <br /> SUBCONTRACTOR <br /> SUBCONTRACTOR w 4LL-0l` YI ot- ASSo'LlI1?ES II '' PHONES q''10- /J / <br /> SUBCONTRACTOR ADDRESS / �N P' yr2l rV LV Co- CTY,,.E/ZIP{Mar��5kK ,q AH GV� <br /> LICENSE C-57 C-61 IJ D-09 I Other NUMBER D S EX RATIONDATE I3,0Ze2 <br /> DOMESTIC WELL SAMPLING:-1 General Mineral/Coliform Bacteria(4391)n Dibromochloropropane(439 )n Arsenic(4393) <br /> INTENDED USE -!Domestic/Private ❑ Irrigation/Agricultural L Industrial 1 Water Quality Monitoring Asoll Sampling/Characterization <br /> -I Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK -i New Well I I Replacement Well C Well Alteration/Modification n Other <br /> -I MonitoringWell(s) #ofwellsXoilBoring(s) JZ- #of borings Geotechnical #of borings <br /> Out-Of-Service Well C Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> I New Pum -1 Pump Replacement n Pump Repair n Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary rt Air Rotary Kuger 1 Pable Tool n Push Point i I Other <br /> Proposed Well Depth IS-Zoft Excavation�in diameter L Open Bottom I_ Gravel Pack/Gravel Size in diameter <br /> .Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/ auge/ASTM Schad C Steel C Plastic n Stainless Steel n Other <br /> Grout Seal Deptht!aP ft Neat Cement(94 lb bag/5-10 gal water) L Sand Cement sack mix/7 gal water <br /> Bentonite 0%sol' s) . Other <br /> Grout Placement Method Pumped ee Fall Other J Retardant/Accelerator(name) <br /> PEDESTAL Installed By 1 I Driller Pump Contractor i Other <br /> Concrete Pedestal❑Dimensions:Width It Length ft Thick in n Christy Box i 1 Stove Pipe <br /> PUMP Submersiblen Turbine rI 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 /> I UM 24 HQUR ADVA NOTICE REQUIRED FOR INSPECTIONS--PLEASE CALL(209)953-769 <br /> SIGNE TITLE / .�EC.7- `� DATE <br /> NT <br /> r <br /> PUMMUVED <br /> ILA 4Z 'A 2019 <br /> COUNTY <br /> NTAL <br /> RTMENT <br /> D AZTENT US O IYLY <br /> Application Accepted By4�1ate Area e ID# <br /> Grout Inspection By Date SPEmploye <br /> SPEC <br /> Well Permit <br /> Pump Inspectlon By Date WAIVER Received <br /> Soil Boring Inspection By Date �� Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date PermW Invoice# WeI11D# <br /> Codes Info s Remitted Service Request# <br /> r 35 <br /> EHD43-06 8101116 ,� ll, ` r^ WELL/PUMPPERMn <br />