SU0013101 - Laserfiche WebLink

Home Browse Search

t WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 -(209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED r/� rn JOB ADDRESS �z/`J `V I' 9 r CITY/ZIP T/�'F Y CROSS STREET I/G!/ ley APN 2 .J M I D D ' PARCEL Sum LAND USE APPLICATION# � OWNERNAME � ii""i]] /�.Li PHONE �� OWNER ADDRESS T A13 CITY/STATEMP CONTRACTOR OCA 4 JJ/��y. PHONE CONTRACTORADDRESS �� / ■ /� CITY/STATE/ZIP V SU CTOR 0+d FE�f1lJt'N 9� D /� d sPHONE SUBCONTRACTOR ADDRESS Ct C` �o �� P�(t4 CA� V-TTY/STATEfZIP LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER E%PIRATION 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 IfWffcmnt from Owner. W.ser ystem amc ConewtNameorPhone,Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Other 13Monitoring Wells) #of wells 13 Soil BoringM of borinaa s) [3Geotechnial 0 of bormp ❑Out-Of-Service Well ❑Out-Of-Service Weil Renewal ss-Connection Repair ❑New Pum ❑Pump Replacement ❑Pump Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sian in diameter � / ❑Conductor Casing in diameter / Conductor Casing Depth ft V Well Casing Diameter in Thickness/Gauge/ASTM Schell ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 Ib bag/5-10gal water) ❑Sand Cement sack mix 17 gal water ❑Bentonite(200/6 solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped O Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Bos ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft 1 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. 1 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. MINIMUM 24 OUR A ANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED I� p„ TTTLE I DATE 17O 131 .4f fl -Ti 1 10 Q , /�D�E�P_A��R'7TT�,MENT/USE ONLY ,�HpEPPRj �'1 /\) Application Accepted By v iC tA�tl-^rJ Date W � Area Employee ID# o Grout Inspection By Date / ❑ SPECIAL Well Permit Pump Inspection By Date �7' �S ❑ WAIVER Received Contry,,cted Well Depth ft COMMENTS A(.Q EAP Pi�D��aLy /NSTALt�,�rl/B /��F,eoY�/ 4 PE SC Received Amount a4 Permit/ Invoice# Well IDN Cods Info Cash Remitted Service Request# SD Satco Q.o° U (LpD a-7Li S 3 EMD 43-02-006 WELL PUMP PERMIT 1/27/2005