SR0067792 - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 1868 East Hazelton Avenue-STOCKTON CA 95205-6232 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 1,w-le- 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRE S -_A9 kec ` c.. ^w `— CITY/ZIP 5±cc Cto m CROSS STREET — r� r`.1 0e t APN 066 w^� .PARCEL SIZE _LAND USE APPLICATION# m C, -- 1Vt J b 7 —YZ7-- y OWNER NAME n O S /V S r! PHONE OWNER ADDRESS / �✓j C� l rr �W may. � ! �V�ITY/STATE/ZIPG'� i � CONTRACTOR �� hCC'_ v� 1 S.SG!)). IC T�' s PHONE CI J' J ✓ /1� y��C /� CONTRACTOR ADDRESS 3oS'2� �n d✓S'rYr �� &vd CITY/STATE/ZIP I^� �S�C��✓''�O'IJ -�sO 1� SUBCONTRACTOR ^�� '--rnc PHONE �C�( SUBCONTRACTOR ADDRESS 3�UC' � CITY/STATE/ZIP CjC "/ t�^ ��'1 /S111/5_1 LICENSE 2<C-57 ❑ C-61 ❑ D-09 ❑ Otherp / NUMBER /�� EXPIRATION DATE ///,;Z1 GEOGRAPHICAL INFORMATION: Coordinates X ` � v3�D / Y 3?i G�J� U Township Range Section INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring XSoil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name Gontact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification C Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION PER RA [Drilling Method ❑ Mud Rotary ❑ Air Rotary ,(Auger ❑ Cable Tool I IED- Proposed Well Depth IC7--15 ft Excavation in diameter ❑ Open Bottom {,❑ Gravel Pack/Gravel Size��in diameter El Conductor Casing in diameter / Conductor Casing f n1 3 hdV�t expred Wiffilo l Well Casing Diameter_ in Thickness/Gauge/ASTM Sched .r I el to Eli �r � ip� Grout Seal Depth 9C� /S'" ft Neat Cement(94 Ib bag/5-10 gal wa r t ❑ an e e sack mix/7 gal water ❑ Bentonite(20%solids) ❑ Other 6y byironmenta� . 1110 BMW Grout Placement Method )(Pumped .)(Free Fall ❑ Other ❑ Retardant/Accelerator(name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft I HEREBY CERTIFY THAT I 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. M 3MUM4 HOUR ADVANCE NOTICUEQUIRED FOR INSPECTIONS SIGNED— —� TITLES o%r�pP`� DATE k RA N H t4A DEPARTMENT U E ONLY Application Accepted By Date Area `f Employee ID# Grout Inspection By Date SPECIAL Well Permit Pump Inspection By Date WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received heck Amount Permit/ Codes Info B sh Remitted Date Service Request# Invoice# Well ID# Loll, 44ul '. 35b' 3 S a 1 z EHD 43-06 WELL/PUMP PERMIT 8/04/08