Laserfiche WebLink
F 1 <br /> IF <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205•(209)468-3420 <br /> NON-REFUNDABLE PERMIT { I. CALL 209 953-7697 FOR INSPECTIONS EXP��I��R��E__S 1 YEAR FROM DATE ISSUED <br /> Joe ADDRESS ,Z7-A3 •� wt)`�� GLeA fLA, CITYZPf*44-/ ( 0- 194L m <br /> LfE��ftF (� A <br /> CROSS STREET APN� I q��OLI' O�I _PARCEL SIzd�b•�3 LAND USE APPUCATK)N# A <br /> ,A A <br /> OWNER NAME r`aryl] � q U�LS 4,1 <br /> �•�'�PHONE 4��tt 17-7 <br /> OWNER ADDRESS �A41 �^t r1.-.., {4y1tow CITY/STATE ZIP I rte• C q ���3y/�/. <br /> CONTRACTOR m ast1lu ►Jif`1111N( I YIC• /PHONE <br /> CONTRACTOR ADDRESS,1 19 16 of S t7d CITYISTATEMP /��0$f l a 9S�s7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITYIISt,STATEMP <br /> LICEN3E `g C-57 ❑C-61 ❑D-09 0 Othef NUMBER fn6 `ZZ EXPIRATION DATE (f–30�ZZ <br /> DOMESTIC WELL SAMPLING:A General MineraUColiform Bacteria(4391)kDibromochioropropane(4392)❑Arsenic(4393) <br /> INTENDED USE ZS Domestic/Private 0 InigationlAgricultural ❑Industrial 0 Water Quality Monitoring ❑Soil Sampling/Characterization <br /> -1 Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> wn <br /> TYPE OF WORK •New Well '*eplacement Well ❑Well Alteration/Modification D Other <br /> U Monitoring Well(s) #of wells ❑Soil Boring(s) s or boring' 0 Geotechnical a of bonngs <br /> C Out-Of-Service Well 0 Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump 0 Pump Replacement 0 Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method 7JCMud Rotary U Air Rotary ❑Auger C Cable Tool 11 Push Point ❑ Other <br /> Proposed Well Depth180 _tt Excavation i!v in diameter ❑Open Bottom k Gravel Pack/Gravel Size JE�6 in diameter <br /> U Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter$in Thickness/Gauge/ASTM Sched_2.9:?O Cl Steel ❑Plastic 'ji6tainless Steel C Other <br /> Grout Seal Depth 245 it 0 Neat Cement(94 Ib bagt5-10 gal wafer) )C Sand Cement /0-3 sack mix/7 gal water <br /> 0 Bentonite(20%solids) ❑Other <br /> Grout Placement Method Pumped 0 Free Fall 0 Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By 0 Driller 0 Pump Contractor ❑ Other <br /> 0 Concrete Pedestal❑Dlmenslons:Width It Length it Thick in U Christy Box ❑Stove Pipe <br /> PUMP 0 Submersible0 Turbine 0 Other HP Pump Sel ft Standing Water Level ft <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 46 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> STONED <br /> TITLE t7w ` DATE y-f b-ZA <br /> -------------- <br /> ------------ <br /> FNT <br /> I VFI6 <br /> ------------ <br /> 22 2020 <br /> H PAR <br /> AL <br /> UI <br /> ARTMFNT <br /> ---------------------------- <br /> / <br /> DEPARTMENRED <br /> Application Accepted By _ I✓ Date l 1 z 0 i'7 Area j 0/�f Employee ID# <br /> Grout Inspection By Date �'/��7r`' SPECIAL Well Permit <br /> Pump Inspection By Date 1 WAIVER Received <br /> Soil Boring Inspection By Date Co tructed Well Depth19S ft <br /> COMMENTS /%/t 'f FuFR <br /> ctJ r lth J l l 5Pc'l afVP;. <br /> PE Sc Receivet Date Perm IV Invoice# Well IDN <br /> Codes Info Service Request# <br /> 36F, c U,ILEHD43-00 8101/18 // �� - WELL/PUMP PERMIT <br />