Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6252(209)468.3420 <br /> NON-REFUNDABLE PERMIT www.sigov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> m <br /> JOB ADDRESS SLI T S CITY/LP M <br /> D <br /> CROSS STREETAPN 09711 PARCEL SIZE , 1 LAMS USE APPLICATION# A <br /> - ' i hhu m <br /> OWNER NAME Q PHONE / o! <br /> OWNER ADDRESS El a451 CITYISTATE/LP <br /> 1 <br /> CONTRACTOR HONE 7 <br /> CONTRACTOR ADDRESS Z O CITY/STATEIZJP <br /> SUBCONTRACTOR/CONSULTANT 3PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS N CITY/STATEZP <br /> LICENSE rC-57 ::C-61 D-09 Other NUMBER q(a b.�Lt EXPIRATION DATE I if 131 1 17-1 <br /> BILLING PARTY: L OWNER AIC <br /> CONTRACTOR - SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:L,General Mineral/Coliform Bacteria(4391)G Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE X Domestic/Private :1 Irrigation/Agricultural Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ':New Well -Replacement Well Well Alteration/Modification Other <br /> Monitoring Wells) #of wells :Soil Boring(s) a of borings Geotechnical #of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal Crass-Connection Repair <br /> New Pump ;KPump Replacement i_Pump Repair l Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method Mud Rotary Air Rotary -Auger Cable Tool -.Push Point - Other <br /> Proposed Well Depth ft Excavation in diameter L Open Bottom !Gravel Pack/Gravel Size in diameter <br /> Conductor Casing in diameter / Conductor Casing Depth it <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Schad -i Steel [ Plastic Stainless Steel ' Other <br /> Grout Seal Depth ft Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mixn gal water <br /> Bentonite(20%solids) Other <br /> Grout Placement Method ❑Pumped Free Fall L Other -Retardant/Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> Concrete Pedestal :Dimensions:Width R Length ft Thick In Christy Box -Stove Pipe <br /> PUMP XSubmersible-:Turbine '. Other HP Pump Set 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 I AM IN COMPLIANCE WITH ALL <br /> WORKERS CO PENSATION LA S. <br /> MII�OU O'nCE REQUIRED FOR IPE'CCTTIIONNSS(-PLEASE CALL(209)9 34769-1 <br /> SIGNED � � TITLE i'` DATEZA <br /> k1 I <br /> I I PAY INV ENT <br /> IVE® <br /> 2020 <br /> COUNTY <br /> ENVEMIAENTAL <br /> RTMENT <br /> DEPARTMENT USE ONLY /) D <br /> Application Accepted By Date Jd 0 <br /> � Area `' Employee ID# I c^ <br /> Grout Inspection By Date + J SPECIAL Well Permit <br /> Pump Inspection By �GV�I.5�9 � u:n Date <br /> "00ji -i. ,I WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cas Remitted Servicq RVquest# <br /> USO _77 <br /> d � <br /> EHD 43-06 6/112019 WELL/PUMP PERMIT <br />