My WebLink
|
Help
|
About
|
Sign Out
Home
Browse
Search
SU0007078
EnvironmentalHealth
>
EHD Program Facility Records by Street Name
>
F
>
FOREST LAKE
>
4777
>
2600 - Land Use Program
>
PA-0800069
>
SU0007078
Metadata
Thumbnails
Annotations
Entry Properties
Last modified
5/7/2020 11:32:51 AM
Creation date
9/4/2019 6:37:04 PM
Metadata
Fields
Template:
EHD - Public
ProgramCode
2600 - Land Use Program
RECORD_ID
SU0007078
PE
2622
FACILITY_NAME
PA-0800069
STREET_NUMBER
4777
Direction
W
STREET_NAME
FOREST LAKE
STREET_TYPE
RD
City
ACAMPO
APN
00319004
ENTERED_DATE
3/21/2008 12:00:00 AM
SITE_LOCATION
4777 W FOREST LAKE RD
RECEIVED_DATE
3/21/2008 12:00:00 AM
P_LOCATION
99
P_DISTRICT
004
QC Status
Approved
Scanner
SJGOV\rtan
Supplemental fields
FilePath
\MIGRATIONS\F\FOREST LAKE\4777\PA-0800069\SU0007078\APPL.PDF \MIGRATIONS\F\FOREST LAKE\4777\PA-0800069\SU0007078\CDD OK.PDF \MIGRATIONS\F\FOREST LAKE\4777\PA-0800069\SU0007078\EH COND.PDF \MIGRATIONS\F\FOREST LAKE\4777\PA-0800069\SU0007078\EH PERM.PDF
Tags
EHD - Public
There are no annotations on this page.
Document management portal powered by Laserfiche WebLink 9 © 1998-2015
Laserfiche.
All rights reserved.
/
43
PDF
Print
Pages to print
Enter page numbers and/or page ranges separated by commas. For example, 1,3,5-12.
After downloading, print the document using a PDF reader (e.g. Adobe Reader).
View images
View plain text
WELL / PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D*RTMENT 304E WEBER71L-STOCKTON CA 95202 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSZdr�&4,9(`��_,r( CITY/ZIP q 5 Z ZO <br /> CROSS STREET APN ��—'"I//V"OS LY_Z 3L <br /> PARCEL SIZE Z AND USE APPLICATION# <br /> OWNER NAME PHONE�,/ / <br /> OWNERADDRESS CITY/STATE/ZIP edld' mo/.J�b . <br /> CONTRACTOR -fPHH�]ONE/ <br /> CONTRACTOR ADDRESS l CITY/STATE/ZIP f �/L <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITV/STATE/ZIP <br /> 0 <br /> LICENSE 16RA�-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X V Township Range Section <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agriculmral 0 Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization <br /> ❑Public Water System <br /> Iftlitierent from Owner: Water System NamContact Nam or Phone Number <br /> TYPE OF WORK ❑New Well ❑Replacement Well ell Afteration/104odification ❑Test Hole ❑Other <br /> ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #ofborings ❑Geotechnical #of bonngs <br /> ❑Well Destruction ❑Out-Of--Service Well ❑O f-Service Well Renewal <br /> ❑New Pum ❑Pum Replacement ❑Pum Repair mss-Connection R air <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary Cl Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> Proposed Well Depth O Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter <br /> ❑Conductor Casing in diameter / Conductor Casing Depth R <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched Cl Steel ❑Plastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth fl ❑Neat Cement(94 Ib hag/5-10ga1 wafer) ❑Sand Cement sack mix/7 gat water <br /> ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor Cl Other <br /> ❑Concrete Pedestal Dimensions: Width R Length—ft Thick in ❑Christy Box ❑Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set O Standing Water Level R <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 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MI UM 4 HOUR ADVANCE NOTICQUI ED FOR INSPECTIONS <br /> SIGNED TITLE r(-K _ DATE Z2- —B� <br /> i <br /> � p U <br /> Of L <br /> N M N <br /> DE RTMENT USE 9QNLY � f N/qq <br /> Application Accepted Byr') Date Area a7-`r Employee ID# �2(,L <br /> Grout Inspection By Date , , ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Destruction Inspection By Date Constructed Well Depth ft <br /> COMMENTS Gln - An <br /> PE SC Received Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Re uesl# <br /> 7 <br /> 13113b 1 a <br /> EHD43-02-00e WELL PUMP PERMIT <br /> Wades <br />
The URL can be used to link to this page
Your browser does not support the video tag.