COMPLIANCE INFO_2002-2006 - Laserfiche WebLink

Home Browse Search

WELL./ PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH IDIWTMENT 304 E WEBER 3a°FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES l YEAR FROM DATE ISSUED rn JOB ADDRESS CITY/ZIP Y CROSS STREET �J� APN 'l% 3 I `✓ Y�ARCEL SIZE LAND USE APPLICATION# OWNER NAME �17 i Yrs Ly !� PHONE OWNER ADDRESS J�! / !��✓ � �l CITY/STATE/ZIP CONTRACTOR ✓'t/r LL f f✓i� PHONE /� CONTRACTOR ADDRESS�T:j z 4�n /-.IV 4_/ &Z�' CITY/STATE/ZIP .1V 1 /QL 4„ SUBCONTRACTOR Ol/ �CCti✓, /,, �I PHONE //O/7 2—— )l�� SUBCONTRACTOR ADDRESS Z 22 � h r! Y` Y �)v�^CITY/STATE/ZIP� M a L ►7✓ CA -7 [ O p LICENSE ❑C-57 ❑C-61 ❑D-09 Other �++ N MBER2Z ZI EXPIRATION DATE �Q GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial 4 Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole AOthc, C 2 ..S �j ❑Monitoring Well(s) #of wells ❑Soil Boring(s) #of borings ❑Geotechnical #of borings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point IgOther Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in dipmeter ❑Conductor Casing in diameter / Conductor Casing Depth ft !g# K 'c/Z_L' Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel IZlastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-/0 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 ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom J4Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94 lb bag 15-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad I HEREBY CERTIFY THAT 1 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. � INI M 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE ,✓ "/ , 5{/ DATE 1N O D n DEPARTMENT//USFL ONLY �� Application Accepted Date V 6 Area Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B a/s Remitted Service Request# _20tP y )�� 2 4L EHD 43-02-006 MASTER WATER WELL PERMIT 12/22/2003