SU0006718 - Laserfiche WebLink

Home Browse Search

� -, �-' sh7�lwadBrlMaer WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH bWARTMENT 304 E WEBER.., 3RD FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED y / F JOB ADDRESS / �L• 1 �� CITY/ZIP y p /� O CROSS STREET i2 /evoke-e APNO Q5OJOL�?�PARCEL SI AND USE APPLICATION# OWNERNAME rC4 PHONE OWNER ADDRESS r e- CITY/STATE/ZIP -70 �17/ �eRYs ! ✓ `•�� CONTRACTOR PHONE CONTRACTOR ADDRESS CITU/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE -57 C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE—4L GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section_ INTENDED USEomestic/Private 13Irrigation/Agricultural ❑Industrial 13 Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System Ifd.ferent from 0.1.,:. Water System Name C..WtN..,Ph.reNvrnb., TYPEOF WORK P New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other ❑Monitoring Wells) #of wells 11 Soil Boring(s) s°rbe.ngs 13 Geotechnical #°fbonnp ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair New Pump ❑Pump Replacement ❑Pump Repair WELL CONSTRUCTION Dri ing Method J[MudRotary ❑Air Rotary ❑Augerr� ❑Cable Tool ❑Push Point 13 Other Proposed Well Depth��_ft Excavation in diameter ❑Open Bottom 'Gravel Pack/Gravel Size—Al—lin diameter \ k ❑Conductor Casing in diameter / Conductor Casing Depth If Well Casing Diameter (.X in Thickness/Gauge/ASTM Sched ❑Steel Wlastic ❑Stainless Steel ❑Other "n Grout Seal Depth /OC> R ❑Neat Cement(94 Ib bag 15-10 gal water) Sand Cement sack mix/7 gal water O . 13 Bentonite(20%solids) 13 Manufacturer Spec%solids % Name //Z -3 ❑Specs on File ❑Specs Submitted Grout Placement Method loumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) f� PEDESTAL Installed By Atriller ❑Pump Corumctor ❑ Other onerete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe �a PUMP ❑Submersible ❑Turbine 13 Other HP Pump Set ft Standing Water Level tt \\\ I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN (,p 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 IMUlN 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED \ TITLE P Y J•' DATE t T D PAT E T r It 'i DEPARTMENT USE ONLY Application Ac y_ Date � /cam., Area Employee 0�-' 6 Grout Inspecti y -- --- Date -7////r ❑ SPECIAL Well Permit Pump Inspect It B Date /.3i ❑ WAIVER Received Constructed Well Depth ft J COMMENTS tom/ L' �(•` PE SC Received ec / Amount Date Permit/ es Well ID# Codes Info B Remitted Service Request# - G- J ru �2ros EHD 4342-006 WELL PUMP PERMIT 142742003