Laserfiche WebLink
PHONE SUBCONTRACTOR/CONSULTANT /tic 1,-( <br />SUBCONTRACTOR/CONSULTANT ADDRESS <br />LICENSE LI C-57 X-C-61 0 D-09 LI Other <br />BILLING PARTY: OWNER <br />CITY/STATE/ZIP <br /> NUMBER /0 (/ 6? 9/ EXPIRATION DATE /0 h/ <br />SUBCONTRACTOR/CONSULTANT CONTRACTOR <br />If different from Owner: <br />es, <br /> <br />Ar Domestic/Private LI Irrigation/Agricultural 0 Industrial 0 Water Quality Monitoring E Soil Sampling/Characterization <br />Public Water System <br /> <br />Water System Name Contact Name or Phone Number <br />Geotech n ica I <br />Cross-Connection Repair <br />Raise Well Casing <br />Well Alteration/Modification E Other <br />Soil Boring(s) # of borings <br />Out-Of-Service Well Renewal <br />Pump Repair <br />Installed By 0 Driller Pump Contractor E Other <br />Concrete Pedestal ElDimensions: Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br />PEDESTAL <br />XSubmersible 0 Turbine U Other HP 2. Pump Set /2 ft Standing Water Level 7 S- / ft PUMP <br />113Apatia._ <br />END 43-06 43-06 6/11/2019 WELL /PUMP PERMIT <br />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.sjgov.orgiehd EXPIRES 1 YEAR FROM DATE ISSUED <br />DOMESTIC WELL SAMPLING: - General Mineral/Coliform Bacteria (4391) _ Dibromochloropropane (4392)1 Arsenic (4393) :993L100V 311S TYPE OF WORK U New Well E Replacement Well <br />Monitoring Well(s) # of wells <br />Out-Of-Service Well <br />kNew Pump U Pump Replacement <br /># of borings <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 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 />-- <br />SIGNED TITLE CO 144-rP C DATE Z- <br />DEPARTMENT USE ONLY <br /> <br />Application Accepted By Date <br /> <br />Grout Inspection By Date <br />Pump Inspection By <br /> <br />Soil Boring Inspection By Date <br />COMMENTS wei .) v Foolli37 0 <br />PE <br />Codes <br />SC <br />Info <br />Received <br />By <br />Chec <br />ash <br />Amount <br />Remitted Date Permit/ <br />Service Request # Invoice # Well ID# <br />3O Ds-) f(-,2;---- *is-c) -11(1a-1 <br />Date 3/72-167"2'7 <br />SPECIAL Well Permit <br />WAIVER Received <br />Constructed Well Depth ft <br />Area <br />NivAiitv7;44 <br />daq <br />/q6-1 7.41047.F: <br />Employee ID# - R <br />Q/VAI <br />I ?to <br />JOB ADDRESS Yte/0 0 J-,) v ; ;-0 4 \ s.i__ CITY/ZIP 9 $T,2 c C <br />CROSS STREET akerOkee APN b g7/) 0 C PARCEL SIZE ' ° 47 LAND USE APPLICATION # <br />OWNER NAME tti :k e-,., Lcs,„ tt.. y c 1 '. 30se ON , PeyeZ PHONE 2-61q 57-0 <br />OWNER ADDRESS Of Of iDit 1-4 " CITY/STATE/ZIP L./D(1 qs-d1-1 ,0 <br />CONTRACTOR IR *(30 be ir --to Ye,,./tr PHONE 2 7 5---c.‘ y 2- <br />CONTRACTOR ADDRESS S / i 2- C coe 4-er- A 1)f' CITY/STATE/ZIP <br />0 ps <br />.54c A-4o CA- $-2 /5— <br />INTENDED USE <br />WELL CONSTRUCTION <br />11 Retardant / Accelerator (name) <br />Drilling Method <br />Proposed Well <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched <br />Grout Seal Depth ft CI Neat Cement (94 lb bag/5-10 gal water) E Sand Cement <br />Bentonite (20% solids) 0 Other <br />Grout Placement Method 0 Pumped LI Free Fall 0 Other <br />Mud Rotary 0 Air Rotary 0 Auger LI Cable Tool 0 Push Point El Other <br />Depth ft Excavation in diameter 0 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter / Conductor Casing Depth ft <br />0 Steel E Plastic E Stainless Steel 11 Other <br />sack mix/7 gal water