SU0013720 - Laserfiche WebLink

Home Browse Search

WELL/ PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3 FL-STOCKTON CA 95202 - (209)468-3410 NGN-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR PROM DATE ISSUED JOB ADDRESS 1`Q (�CrrY/-7 -rIPMC1rj!jt& 21L C.4 -1 q,9 JQ CROSS SrFUEET APN c� l5 D /Q Q PARCEL SIZE 1- 1, �L OWNER NAME PHONE OWNER ADDRESS CLTY/STATE/ZI P �ss,?:�co CONTRACTOR PHONL �+�1•e)1 CONTRACTOR ADDRESS CrrYMATTFLIP c,�, (OG SUBCONTRACTOR PHONE SUSCONTRACrOR ADDRESS_ CRY/STATFIZIP LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other C.\n NUMBER�,;�L EXPIRATION DATE ZQE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE omestic/Private ❑IrrigatiordAgricultvral ❑Industrial ❑Water Quality Monitoring Cl Soil Sampling/Characterintion ❑Public Water SyysSt[eefmn Idiffaenr from 0wi—. neer yso+na f Conisd N ofPhomMumba TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other Q ❑Monitoring Wcll(s) nuffkv of wells ❑Soil Boring(s) number of borinµs ❑Geotechnical number of boring% O ❑Well Destruction ❑put-Of--Service Well ❑Out-0f--Service Well Renewal cw Pump Pump Rc lat:ement ❑Pump Repair ❑Cross-Conne.:tion Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth A Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter M ❑Conductor Casing in diameter / Conductor Casing Depth II Well Casing Diameter in Thickness/GaugeIASCM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth R ❑Ncat Cement(94 lb bag/5-10 gal wafer) ❑Sand Cement s«•k mix/7 gal water ❑Bentonite(20%colids) ❑Manufacturer Spx%solids % Name _ ❑Specs on File ❑Specs Submitted Q Grout Placement Method ❑Pumped ❑Free Fall ❑Other_ ❑Retardant/Accelerator(frame) PEDESTAL Installed By ❑Driller ❑Pump Contractor Cl CMler ❑Concrete Pedestal Dimensions: Width rZ Length ft Thick in ❑Christy Bort ❑Stove Pipe PUMP 'Submersible ❑Turbine ❑OtherHP T Pump Set��ft Standing Water Level ft WELL DESTRUCTION 0 Open Bottom ❑Gravel Pack L Uncased ❑Other Well Diameter in Total Depth ft Depth to Watrr ft ❑Casing to be Perforated from ft to n Setting Material ❑Neat Cement(94 16 bag/S-10gal wurer) ❑Sand Certent sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids__% Name ❑Specs on Pile ❑Spm Submitted Placement Method ❑Pumped ❑Free Fall ❑Other_ ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pod 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. IMUM 24 HOUR Ab CE NOTiC REQUIRED FO 1 E��CI -?LEASE L(209)9 3--7697 SIGNED TITLE cur`/ DATE ;2 G iA IT imy 0 qq DEPARTMENT USE LY p Application Accepted'dy Area ZI D Employee IDN q 3 Groul Inspection By Dau ❑ SPECIAL Well Permit Pump Inspation gym f� Dau�� i��% El WAIVER Received DoInspection truction By Date Constructed Well Depth tt COMMENTS PE SC Received Amount Date Permit! IRvoleeN Well IDN Coder Ido B Caib Remitted Service Request N BHD 43.02.006 MASTER WATER WELL PERMIT 1114nm1