Laserfiche WebLink
WELL / PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3p° FL - STOCKTON CA 95202 - (209) 465-3420 <br />STREET <br />(NAME <br />PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES i YEAR FROM DATE ISSUED <br />CITY/ZIP f -21J <br />1110— 191d - APN �'-� tSCI t ( PARCEL SIZE /- 0- LAND USE APPLICATION # <br />PP�HONN�E'��+ <br />3 CITY/STATE/ZIP—�rL/erCQQ�7Qt <br />�.:.) � 44PHONE rf6j Q;ZV.1 C-)_ <br />2 CITY/STATF/ZIPC_ kdA� % `./ Y 1 1 <br />/ w PHONE 1. <br />LICENSE ❑ C-57 AC -61 ❑ D-09 ❑ Other NUMBER' ► $ I (Q EXPIRATION DATE <br />GEOGRAPHICAL INFORMATION: ['—dinatea X V T..v...Al.. 0...... c--u-- <br />PIENDED USE estic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring 0 Soil Sampling/Characterization <br />- ❑ Public Water SyysStem <br />Vditfereotfrom Uvner. Waver System Nemc Cmt Name or Phom Number <br />TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br />❑ Monitoring Wells) # of wells ❑ Soil Borings) s of bodm ❑ Geotechnical tt of boa p <br />❑ Out -Of -Service W 11 ❑ Out -Of --Service Well Renewal ❑ Cross -Connection Repair <br />❑ New Pump Pump Replacement ❑ Pump Repair <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool Cl Push Point ❑ Other <br />Proposed Well Depth R Excavation in diameter ❑ Open Bottom ❑ Gravel Pack / Gravel Size in diameter <br />❑ Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter _ in Thickness/Gauge/ASTM Schell ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br />Grout Seal Depth It ❑ Neat Cement (94 /b bag/5-/0 gal water) ❑ Sand Cement sack mix / 7 gal water <br />❑ Bentonite (201/ solids) ❑ Manufacturer Spec % solids _% Name ❑Secs on File ❑ Specs pets Submitted <br />Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) <br />PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br />[]Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑ Christy Bos ❑ Stove Pipe <br />PUMP Submersible ❑ Turbine ❑ Other _ HP Pump Set ft Standing Water Level ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />1P <br />IN <br />rL <br />? DEPARTMENTU E ONLY y/ <br />Application Accepted By - Date Y �C.� Area Employee ID# 'S 3In6 1 <br />Grout Inspecti y Date L3 SPECIAL Well Permit <br />Pump Inspecon B Date_ �/«1�- ❑ WAIVER Received <br />Constructed Well Depth ft <br />COMMENTS <br />PE SC Received Chec <br />Codes Info By <br />Amount <br />emitted <br />Date Permit/ Invoice fl Well IDN <br />Service Re u # <br />Fi <br />ERD 43-02-1x16 WELL PUMP PERMIT <br />127/2005 <br />