COMPLIANCE INFO_1988-2004 - Laserfiche WebLink

Home Browse Search

WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEWMENT 304 E WEBER RD FL - STOCKTON CA 95202 - (209) 468-3420 IN VIN -REFUNDABLE PERMIT (-ALJ. (ZU9) 953-7097 FOR INSPECTIONS EXPIRE) 1 YEAR FROM LATE ISSUED JOB ADDRESS CITY/ZIP CROSS STREET APN PARCEL SIZE LAND USE APPLICATION # OWNER NAME PHONE OWNER ADDRESS CITY/STATE/ZIP CONTRACTOR PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑ C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section NTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization ❑ Public Water System If different from Owner: Water System Name ontactName or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Monitoring Well(s) # of wells ❑ Well Destruction ❑ Well Alteration/Modification ❑ Test Hole ❑ Other ❑ Soil Boring(s) # of borings ❑ Geotechnical ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal # of borings 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE DATE Application Accepted By Grout Inspection By. Pump Inspection By Destruction Inspection By. COMMENTS DEPARTMENT USE ONLY Date Date Date Date Area Employee ID# ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft rn �y b O y H PE Codes U New Pump U Pump Replacement U Fump Ke air Li Cross -Connection Ke air WELL CONSTRUCTION Amount Remitted Date Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point rgOther �i L -D Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack / Gravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth ft ❑ Neat Cement (94 lb bag 15-10 gal water) ❑ Sand Cement sack mix / 7 gal water ❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids % Name ❑ Specs on File ❑ Specs Submitted 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 It 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE DATE Application Accepted By Grout Inspection By. Pump Inspection By Destruction Inspection By. COMMENTS DEPARTMENT USE ONLY Date Date Date Date Area Employee ID# ❑ SPECIAL Well Permit ❑ WAIVER Received Constructed Well Depth ft rn �y b O y H PE Codes SC Info Received By Check#/ Cash Amount Remitted Date Permit/ Service Request # Invoice # Well ID# 3 EHD 43-02-006 WELL PUMP PERMIT 8/6/04