Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1648 EAST HAZELTON AVENUE-STOCKTON CA 86205-(208)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> In <br /> JOB ADDRE89 /I r./Q/ .(7W iltow G �yt t` <br /> a -A, Crryrzip a l_ irQ. � AA <br /> ` bbb <br /> CROSS STREET `JYtCnl�l� rK� APN I9I-OSI' jI _PARCELSIZE74•`3 LAND USE APPP�UCATION# <br /> M <br /> OWNER NAME CL( IA <br /> • o 1 4eS PHONE 14eepL119 I <br /> OWNER ADDRESS yl� +,S (ef1r-1L1 �40I6UI) F"'• CITYISTATEIZIP Ir'�•�rCq 7377 <br /> CONTRACTOR M Ql{lI IJ ►Ji`7 Ill Nt I YI�• PHONE 5 22/x-192-(f6! C`7 <br /> CONTRACTOR ADDRESS•�I 16 tr S �Z�• CrTYISTATEIZIP(f/t/)0/.S/O <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CrTY/ST(ATEILP f I <br /> LICENSE `f(C-S7 U C-01 O D-09 ❑Other. NUMBER d2S 2,z F_xPIRATION DATE <br /> DOMESTIC WELL SAMPLING:XGeneral Mineral/Coliform Bacteria(4391)kDlbromochloropropane(4392)D Arsenic(4393) <br /> INTENDED usr -9DomestldPdvate 0 Irrigellon/Agdcullural D Industrial D Water Quality Monitoring ❑Soil Sampling/Characterization <br /> U Public Water System <br /> Indifferent I—Owner. Wel.!System Neme Contact Name or Pftone Number <br /> TYPE OF WORK 'New Well 'Weplecement Well D Well Alterallon/Modificallon D Other <br /> U Monitoring Well(s) #of wells D SoilBOdng(s) iofbor1np` D Geotechnical eo10or1ngs <br /> +0 Out-Of-Service Well D Out-OfServlce Well Renewal D Cross-Connection Repair <br /> 0 New Pump 0 Pump Replacement O Pump Re air D Raise Well Cesln <br /> WELL CONSTRUCTION <br /> Drilling Method VMud Rotary O Air Rotary D Auger D Cable Tool D Push Point 0 Other <br /> Proposed Well Depth 6Q_ft Excavation- fq In diameter ❑Open Bottom A Gravel Pack/Gravel Slze-21L�Apl_In diameter <br /> U Conductor Casing in diameter / Conductor Casing Depth ft <br /> Wall Casing Diameter.$In, Thickness/Gauge/ASTM Sched 2j9ZP0 D Steel ❑Plastic `jOtalnless Steel ❑Other <br /> Grout Seal Depth 46 it 0 Neal Cement(94 lb begl5-10 gat Iveter) X Sand Cement /O-3 sackmlxr7 gal water <br /> D Bentonite(20%solids) D Other <br /> Grout Placement Method X Pumped ❑Free Feil D Other 0 Retardant/Accelerator(name) <br /> PEDESTAL, Installed By D Ddiler 0 Pump Contractor ❑ Other <br /> D Concrete Pedestal❑Dimenslons:Width It Length It Thick in U Christy Box 0 Stove Pipe <br /> IMP ❑SubmersibleU Turbine 0 Other HP Pump Sol it Standing Water Level fl <br /> 1 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 48 HOUR ADVANCE NOTICE REQUIRED FOR� INSPECTIONS-PLEASE CALL(209)953.7697 <br /> SIGNED w'7 TITLE Vn— DATE <br /> lENT <br /> QED <br /> 22 2020 <br /> UA16�0VNry <br /> PARTMFNt <br /> 'Am id <br /> DEPARTMEN USE ONLY <br /> Application Accepted By � Dale 7 z /U6 0 Area qq j Employee ID# <br /> Grout Inspection By Date 6QWAIVER <br /> WBII Permit <br /> Pump Inspection By Date ,6Q WAIVER Received <br /> Soil Boring Inspection By Date H Cort/stru�cted Well Depth tt <br /> COMMENTS ✓n(J,;f 5611 tO r)exi C c,I_LI/e c�S prr }LIP PPf J tr/PI 5F�! vi"VP(. <br /> Chsc # Amount Permit/Recelved Well ID#PE SC Date <br /> Codes Info ash Remitted Tu Service Re uaet# <br /> 366 o SGL DC7 <br /> c <�� � l S- Z• p 0 <br /> G� Li <br /> . 70 d 11,W 00 <br /> DSWELL rPU1AP PERMR <br />