Laserfiche WebLink
1� <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205 -6232 (209) 468-3420 <br />NON -REFUND E PERMIT www.sjgov.Gr/g EXPIRES 1 YEAR <br />JOB ADDRESS 1VVlrL� CITY rct 0 <br />a a� (,o o 0 ; <br />CROSS STREET ��( G IAPN \/ /` J� PARCEL SIZE a LAND USE APPLICATION # <br />OWNER NAME Q ,�e' <br />14 %t J V • IPHONE'-7L4-7 <br />�H)ONE � n <br />OWNER ADDRES K lY p 1. ) CITY, 1 V `' <br />CONTRACTOR ET Ln I li V1. _ \J / p� HON <br />CONTRACTOR ADORES �JJW ! Ii TSTA PJ{ �/ <br />SUBCONTRACTOR/CONSULTANT A <br />J��/P 1�f. <br />SUBCONTRACTOR/CONSULTANT ADDRESS I ISTATErzIP r I� <br />LICENSE C-57 X C-61 D-09 Other/D 2 NUMBER 4:t� O EXPIRATION A J <br />BILLING PARTY: OWNER XCONTRACTOR SUBCONTRACTOR/CONSULTANT <br />)OMESTIC WEL SAMPLING: General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) Arsenic (4393) <br />NTENDED USE Domestic/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 <br />TYPE OF WORK New Well Replacement Well <br />Monitoring Well(s) # of wells <br />Well Alteration/Modification Other <br />SoilBoring(s) #of borings Geotechnical <br />Out -Of -Service Well Renewal Cross -Connection Repair <br /># of borings <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth It Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter <br />Conductor Casing in diameter 1 Conductor Casing Depth ft <br />Well Casing Diameter ,_ in Thickness/Gauge/ASTM Sched Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Neat Cement (94 Ib oag/5-10 gal water) Sand Cement sack mix17 gal water <br />Bentonite (20% solids) Other_ <br />Grout Placement Method Pumped Free Fall Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller Pump Contractor Other <br />Concrete Pedestal Dimensions: Width _ It Ley ft Thick in Christy Box Stove Pipe <br />ri <br />PUMP IV Submersible Turbine Other HP Pump Set ft Standing Water Level It <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 />WOONSATION LA <br />CMIINIMI ]MAR HOl nV E NOTICF RE(]LIIRFD FOR INSPECTIONS -PLEASE CALL (2091 9 - 7 ) <br />SIGNED <br />Y) ) 1, // I DATE 151 <br />DEPARTMENT E O LY <br />Application Accepted By Date _y . I Area q1 Cf� Employee ID# <br />AG <br />Grout Inspection By _ Date SPECIAL Well Permit <br />Pump Inspection By Date WAIVER Received <br />Soil Boring Inspection By Date _ Constructed Well Depth ___ft <br />COMMENTS <br />_N <br />g <br />0 <br />m <br />N <br />Im <br />r) <br />O <br />12,1 <br />F yMFNT <br />C�c�VED <br />IN ? 4 ?0?1 <br />4 QUIN <br />ARV7_4�NTy <br />NT <br />PE <br />Codes <br />SC Received Check#/ Amount ate Permit/ Invoice # Well ID# 7 <br />Info B Remitted Service Re nest # <br />3 <br />_ <br />O $O <br />EHD 43.06 611112019 WELL /PUMP PERMIT <br />