Laserfiche WebLink
Rd aff) <br /> M(A -- 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 f( www.s ov.or /ehd EXPIREf�S,1 YEAR <br /> jFROM <br /> SDATE ISSUED <br /> JOB ADDRESS Lq <br /> US z V S e nrtt �f CITY/ZIP LrA <br /> ' ✓ tJ(J N <br /> -i <br /> m <br /> 11_---� 5.1.E a D <br /> CROSS STREET U+hm�1 ley- �,,�/ jA�PN�01 j1q 0D0a /� PARCEL SIZE L �DU/SE APPLICATION# <br /> 1 vv � IvV• v / iLX� I m <br /> � Vt e ry e PHONE — y <br /> OWNER NAME <br /> OWNER ADDRESS CITYIST T IP <br /> CONTRACTOR � e� t�` � t PHONE �� v �= <br /> CONTRACTOR ADDRESS V Ito 0 <br /> d CITY/STATE/ZIPy J 3�0 <br /> ISUBCONTRACTOR/CONSULTANT PHONE S <br /> SUBCONTRACTORICONSULTANTADDRESS . CITY/STATE/ZIP /9 <br /> ` <br /> 211 Q1 (. u(P 0 I CA3 o <br /> LICENSE _ G57 C-61 _ D-09 _ Othe NUMBER EXPIRATION DATE OD <br /> BILLING PARTY: OWNER CONTRACTOR -1 SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WEL SAMPLING: ❑General Mineral/Coliform Bacteria(4391)= Dibromochloropropane(4392)u Arsenic(4393) <br /> INTENDED USE omestic/Private - 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 �p <br /> TYPE of WORK _ New Well � Replacement Well U Well Alteration/Modification _ Other <br /> `v <br /> - Monitoring Well(s) #of wells n Soil Boring #of borings s) - Geotechnical #of borings <br /> _ Out-Of-Service Well L Out-Of-Service Well Renewal a Cross-Connection RepairRC� CN,` <br /> New Pum ❑ Pum Replacement Pum Repair C Raise Well Casing <br /> CC <br /> WELL CONSTRUCTION AUG <br /> Z3_Drilling Method _ Mud Rotary U Air Rotary Auger _ Cable Tool Push Point _ Other �`I Vrj ' <br /> wzu <br /> Proposed Well Depth ft Excavation in diameter _j Open Bottom Gravel Pac *,; in diameter <br /> _ Conductor Casing in diameter / Conductor Casing Depth ft NEALTI4 0/NVMENTq /NV <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched _j Steel J Plastic _ Stainless Steel 't7 9p L n <br /> Grout Seal Depth ft n Neat Cement(94 lb bag/5-10 gal water) 7, Sand Cement sac 1x/7 gal water <br /> - Bentonite(20%solids) - Other <br /> Grout Placement Method - Pumped n Free Fall n Other F. Retardant/Accelerator(name) <br /> .IPEDESTAL Installed By = Driller 73 Pump Contractor L Other <br /> L— <br /> _ Concrete Pedestal uDimensions:Width ft Length ft Thick in _ Christy Box LI Stove Pipe <br /> of <br /> PUMP Submersible- Turbine n Other HP Pump Set ft Standing Water Level ft G <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH §AN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 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 /> MINNIIIMU 44 I VANCE NOTICE REQUIRED FOPp.. <br /> .INSPECTIONS -PLEASE CALL (20 3-776 7 <br /> SIGNED L TITLE `�y-yl (t// Sao DATE Z r' <br /> i <br /> C. <br /> C. <br /> T� DEPARTMENT USE ONLY <br /> Application Accepted By r/"' Ll Date e Ia d 0,2 0 Area S Employee ID# F2 <br /> Grout Inspection By Date E SPECIAL Well Permit <br /> Pump Inspection By r�LtS La .pgn1 .. &4,, Date ((I 14(U2-P WAIVER Deceived <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received hec Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> '4320 0�cP $7 q-1740 -- <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />