Laserfiche WebLink
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 / G w www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSU,�E�D, <br /> JOB ADDRESS 73d 5 Nnr IyAy`i� 12-4• CITY/ZIP / �+��t+/��Yy 1 <br /> CROSSSTREET FL'PD�j ,`d, 44 D <br /> n t APN �13-���1�Z� PARCEL SIZE�LAND USE APPLICATION# A <br /> OWNER NAME IVA R--At,9 !f'64,e,+1-0AoV ITI r F'r PHONE r? <br /> OWNER ADDRESS /(/�'J�,/W�J n/et�7.Z/r 5r CITY/STATE/7J FA�2,Ilsl•✓'J4�rON 40 <br /> CONTRACTOR �' -' r T �'�' j�G F71ONE 9 —Z <br /> CONTRACTOR ADDRESS /Y Cvc-4-t- J e7'• CITY/STATEIZIP Sp""�44 f, 37O <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS CIN/STATE/ZIP <br /> LICENSE 4 C-57 ❑C-61 ❑D-09 0 Other NUMBER L/;k57Y'f- EXPIRATION DATE / 2/ <br /> BILLING PARTY: ❑OWNER 0 CONTRACTOR 0 SU13CONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:❑General Mineral/Coliform Bacteria(4391)G Dibromochloropropane(4392)Q Arsenic(4393) <br /> INTENDED USE G Domestic(Private Irrigation/Agricultural ❑Industrial 0 Water Quality Monitoring ❑Soil Sampling/Characterization <br /> U Public Water System <br /> If different from Owner. Water System Name Cont.11 Name or Phone Number <br /> TYPE OF WORK X New We0 ,❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Borings) #of borings 0 Geotechnical #ofbonngs <br /> ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pum ❑Pump Replacement ❑Pump Repair ❑Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method,6�yud Rotary D Air Rotary ❑Auger O Cable Tool U Push Point ❑ Other <br /> Proposed Well Depth ft Excavation- in diameter 0 Open Bottom 'Gravei Pack/Grevei Size =' E�in diameter <br /> ,_`Conductor Casing /f'5 in diameter / Conductor Casing Depth � ft <br /> Well Casing Dlameter_Lin Thickness/Gauge/ASTM Sched i T_ ❑Steel lCPIasfic ❑Stainless Steel ❑Other <br /> Grout Seal Depth eP It ❑Neat Cement(94/b bag/5-10 gal water) ❑Sand Cement sack m&/7 gal water <br /> Bentonite(20%solids) ❑Other <br /> Grout Placement Oethod XPumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal DDlmensions:Width ft Length If Thick-- in ❑Christy Box ❑Stove Pipe <br /> PUMP - ❑Submersible:)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 COMPENSATION MWS. <br /> MI Ult� H UR ADVANCE N TICE REQUIRED FOPYNSPECTIONS-PLEASE CALL(209)953-7697 <br /> SIGNED TIRE ��GN DATE 0 �O <br /> Yi�ENT <br /> CEIv�® <br /> I . <br /> FF'- <br /> jop'QUN ENTA V <br /> 1 . � RONM TMENT <br /> ?H DEPAR <br /> DEPARTMENT USE ONLY <br /> Application Accepted By � Date <br /> ) Area Ll Cr ff Employee ID# -- <br /> Grout Inspection By AGJ v "I + Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection)By <br /> ' Date ) CG^^`vcted Well Depth . ft <br /> _ ✓f ��c%LPCOMMENTS C•)) Ff-,e- j,,,, 1 <br /> PE SC R iv d e Amount Date Permit/ Invoice# Well ID# <br /> Codes Info Cash Remitted ice Re uest# <br /> UIC, WC. J lz <br /> 43-06 6111(1019 WELL RUMP PERA1rr <br />