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.S. OV.O! /ehd EXPIRES'I YEAR FROM DATE ISSUED <br /> JOB ADDRESS I/�7``t 00 Cn Q S T 14AtAi y a A Qq� CITY/Zip I f�y . C.� y S3 m <br /> CROSS STREET Div fT-nF" Jul^L-M p �0�Z"O 3-Q D <br /> APN Z Q\' I PARCEL SIZE LAND USE APPLICATION# v <br /> _y (� m <br /> '1W \ <br /> OWNER NAME (�A 1 1 n.5 T��S�• PHONE D�5 <br /> OWNER ADDRESS P w' ���$�' 1 15�I��'-) I`� r� CITY/STATEMP TFAC7 -A 9 CS3 S I <br /> CONTRACTOR M-4,0AZO `,T 0 "^r)IOI��E�1�rr 'L.� cPHONE ZCQ $0 -10cp c� <br /> CONTRACTOR ADDRESS O 3 ! S`l A,V./ A O A, CITY/STATEZP J 10 1 O/� C-,T Y ZI� <br /> r f l ! <br /> SUBCONTRACTOR/CONSULTANT M�.S A /T S "A T/3 0PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS It %/ CrrYISTATE/ZIP I t I <br /> LICENSE -71,C-57 C-61 D-09 "Othef NUMBER (03 P Z'f—I EXPIRATION DATE I^ 3 <br /> BILLING PARTY: OWNER ONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING 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 fmm Owner. Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br /> MonitoringWell(s) #of wells SoilBodng(s) #o16onno Geotechnical 0ofbonngs <br /> Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pum Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary -('CAuger Cable Tool Push Point Other <br /> Proposed Well Depth Nil A it Excavation u I.It in diameter Open Bottom -Gravel Pack/Gravel Size NI A� in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad Steel i Plastic ,Stainless Steel Other <br /> Grout Seal Depth 15 ft Meat Cement(941b bag75-10 gal water) Sand Cement sack mix/7 gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method umped - Free Fall J Other CM VL .- Retardant/Accelerator(name) <br /> PEDESTAL Installed By -:Driller Pump Contractor Other <br /> -Concrete Pedestal_Dimensions:Width ft Length ft Thick in Christy Box . Stove Pipe <br /> PUMP Submersible 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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MMIIsNIMUM 48 H R A!`T,IAN E NOTICE REQUIRED FOR(INSPECTIONS-PLEAS(E,CAALL(209)953-7697 <br /> / C <br /> SIGNED W+-- ��' TITLE rt'S�aS�1 • �A V'tl DATE 12-—I Z O I 1 <br /> MFNT <br /> VFO <br /> ?0,9 <br /> tires n <br /> rMFNt <br /> DEp_ARTMENT U E O LY /1/ <br /> Application Accepted By _Date Area G Employee I -I:! 1[A <br /> Grout Inspection By Date h PEC IAL Well Permit <br /> Pump Inspection By Date I WAVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Chec Amount Date Permitl Invoice# Well ID# <br /> Codes Info Bsh Remitted Service Request# <br /> L' <br /> EHO 43-06 6111/2019 WELL(PUMP PERMIT <br />