Laserfiche WebLink
• SAN JOAQUINCOUNTY ENVIRONMENTAL HEALTH DEPART AWELL/PUMP PERMIT <br /> 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)468-3420 <br /> NON-REFUNDABLE PERMIT ENT wwW,S' py,pr /ghd <br /> EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ^ N <br /> ' �j CITY/ZIP =LA <br /> CROSS STREET ' APN 0 JI J L L QD <br /> L PARCE{L SIZE I'J O <br /> OWNER NAAIE Ed (�{ R-j1%\� - �,:li1 F'S i- 'fht rr� 'rPo <br /> OWNER ADDRESS "� ' J�� �4 I, � "on �� CITYISTATE/ZIP .�1 <br /> CONTRACTOR 11 1 S SN�- irVIG v] <br /> ''') J �' PHONE <br /> CONTRACTOR ADDRESS L q4 l <br /> CITY/STATEIZIP T-{F-ar -'}SnL_ Jo' <br /> SUBCONTRACTOR/CONSULTANT <br /> PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS jttA- <br /> CITYISTATE/ZIP <br /> LICENSE `Qf C-57 C-61 -D-09 �Other <br /> BILLING PARTY: NUMBER��� EXPIRATION DATE / <br /> OWNER ACONTRACTOR "i SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391)_Dibromochloropropane(4392) Arsenic(4393) <br /> n"M5,�e Irrigatpgaracterization <br /> stemer Walar System Name <br /> Contact Name or Phone Number <br /> TYPE OF WORK -- New Well - Replacement Well Well Alteration/Modiffcalion <br /> Other <br /> Monitoring Wells) #of wells Soil Borings) u of borings <br /> Out-Of-Service WellGeotechnical 4 of borings <br /> Out-Of-Service Well Renewal Cross-Connection Repair <br /> -New Pum um Re lacement C Pum Re air <br /> WELL Com oN Raise Well Casin <br /> Drllling Method Mud Rotary _ Air Rotary _Auger Cable Tool Push Point <br /> Proposed Well Depth ft Other <br /> Excavation in diameter -Open Bottom Gravel Pack/Gravel Size <br /> Conductor Casing in diameter / Conductor Casing Depth ft n diameter <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched <br /> Grout Seal Depth ._Steel _Plastic -Stainless Steel Other <br /> P ft Neat Cement(94 Ib bag/5-10 gal water) Sand Cement <br /> Benlonite(20%solids) _:Other Sack mixR gal water <br /> Grout Placement Method - Pumped Free Fall =:Other <br /> -Retardant/Accelerator(name) <br /> !PEDESTAL Installed By Driller -Pump Contractor _ Other <br /> Concrete Pedestal Dimensions Width ft Length Th Thick <br /> Ff n Christy Box Stove Pipe <br /> uMPSubmersible_Turbme __ Other HP Pum Sel <br /> P <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE ft Standing Water Level If 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 L <br /> C ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL;209)953 <br /> _- 97 <br /> SIGNED / -.� ,�^r� ) _' � � <br /> TITLE L✓ DATE ;7, z�� <br /> INC:uNTy <br /> ENT <br /> DEPARTMENT USE ONLY <br /> Application Accepted By liF� �� �, <br /> Date Area f <br /> Grout Inspection By Employee ID# <br /> Date <br /> Pump Inspection By Date SPECIAL Well Permit <br /> '� '), _ <br /> Soil Boring Inspection By Date WAIVER Received <br /> COMMENTS Constructed Well Depth ft <br /> PE SC Received Check#/ Amount <br /> Codes Info B C Da Permit/ <br /> Remitted <br /> o 7 S 1 e e e Invoice I Well ID# <br /> DISK) �� Z- l# <br /> =HD 47?i 6-12019 <br /> VI=-LL IPUM.P PERMIT <br />