SU0012053 - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET•STOCKTON CA 95202•(209)468-3420 NON-REFUNDABLEPERMIT CALL 209(79553-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED m Joe ADDRESS rr--'l 111 M�� a_c�lL1 Cm/Zip ct^ C-CpC"T�� ID CROSS STREET rl U CZ1 APN I (-3- (i0-O ^PARCEL SIZE Q" LAND USE APPLICATION#_ m fa 1 y� PHONE 943C)-c-4841 � OWNER NAME M 0.`1� �`�oV� _ OWNER ADDRESS p CITYISTATEIZIP CONTRACTOR d0. ` \� PHONE CONTRACTOR ADDRESS 3 AI O 7-. fv Q' , `lCITY/STATE/ZIP SUBCONTRACTOR ,_ PHONE SUBCONTRACTOR ADDRESS CITfISTATEIZIP LICENSE ,jk C-57 AC-61 D 0-09 r-I Other NUMBER $r1'1`St3 EXPIRATION DATE O I f 4� GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Soalon INTENDED USE A Domestic/Private C IrrigatlonlAgdcultural C Industrial L Water Quality Monitoring ❑Soil Sampling/Charactenzation G Public Water System UortaCtams or lions um er It dlfferefetrom Owner er ys m ams TYPE OF WORK New Well 7 Replacement Well C Well AlterationfModification ❑Other t of borings #of borings L]Monitoring Wells) #of wells G Soil Borings) L Geotechnical_ 0 Out-Of-Service Well ]Out-Of-Service Well Renewal C Cross-Connection Repair in New Pump C Pump Replacement Pum Re air WELL CONSTRUCTION Drilling Method n Mud Rotary D Air Rotary L Auger 7 Cable Tool (I Push Point C Other W Proposed Well Depth It Excavation in diameter r Open Bottom ❑Gravel Pack/Gravel Size in diameter 7 Conductor Casing in diameter I Conductor Casing Depth ft IT Well Casing Diameter_in Thickness/Gauge/ASTM Sched I Steel -1 Plastic D Stainless Steel IJ Other Grout Seat Depth ft C Neat Cement(941b bagl5-f0 gal water) D Sand Cement Sack-mixO gal water 1.Bentonite(20%solids) D Other Grout Placement Method C Pumped ❑Free Fall D Other D Retardant/Accelerator(name) O PEDESTAL Installed By G Driller ❑Pump Contractor D Other 7 Concrete Pedestal Dimensions'.Width ft Length ft Thick in C Christy Box C Stove Pipe PUMP '1Submersible7 Turbine C Other HP---L— Pump Set W.S ft Standing Water Level it f� 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 t AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. r MI UM 24 H ttM ADVANCE NOTICE RE RED FOR INSPECTIONS _ SIGNED TITLE DATELS �Q- I � I I 1 I 1 ' I 1111 .-�.. - it i I i F A U M E r rl L (//'�� DEPART ENT USE ,, ONLY Application Accepted By ✓/"`--' Date d &-e Area Employee ID# 73 9 9 Grout Inspection By Date 0 SPECIAL Well Permit Pump Inspection By �i Date ld ❑ WAIVER Received Soil Boring Ins on By _ Date Constructed Well Depth ft COMMENTS /fx PE SC I Received Choc Amount Penult/ Codes Inco B Cash Remitted Date Service Re uest# Invoice# Well ID# ` -so. zq,10e SRoa q 0P00,L -7 EHD 43-06 WELL/PUMP PERM!" 911&07