BP-1401483 Demo sign off - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS5 J�,� 2X��f flF + CIN/ZIP-7C4/u ` 6v( L/�' - lS o��C� In CROSSSTREET #C/All /21 APN i. n t Cat>i> gip- 3 13 l PARCEL SIZE LAND USE APPLICATION# m � � � ` 7 p �/� m / \ � �V�rL PHONEV-2 �) L�:I6 '�T` N OWNER NAMEy��.//L'l.i�-7c Y. �J QC �L-a OWNER ADDRESS �7Lo ( � f �(.I. ��Cwt�?'i CITY/STATE/ZIP _' �s 3�26 CONTRACTOR PHONE CONTRACTOR ADDRESS CITYISTATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CIN/STATE/ZIP LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range_ Section _ INTENDED USE ❑ DOmestiC/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water 6ystem Name on a ame or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other ❑ Monitoring Well(s) #ofwells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings f�0ut-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pum ❑ Pum Re lacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger Cable Tool ❑ Push Point ❑ Other Proposed Well Depth It Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter ❑ Conductor Casing in diameter ! Conductor Casing Depth ft Well Casing Diameter—in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal Dimensions:Width It Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set It Standing Water Level ft I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. , I UM 24YO DVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 SIGN Q 'e/!/ .lLalira( TrrbE r; l DEPARTMENT USE ONLY rJit— t � Application Accepted By I ;rr"-" �-- Date ' t Area oLtl C Employee 0#11- Grout D#1 "Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Soil Boring Inspection By Date Constructed Well Depth It COMMENTS "tea C- T-L i-4' k3-c. G''azy4eG ' (. , y � �- i2..r-�r� t � - -aGs-y wi lr S-� Ih�J a�oz�,f (�,dld.:�� 'l I-� PE SC Received Check#/ Amount Date Permit/ Invoice# WeII ID# Codes Info By Cash Remitted Service Request# EHD 43-06 WELL/PUMP PERMIT 4I3n/12