WP0038686 - Laserfiche WebLink

Home Browse Search

t: i WE L L I P U-PV1i P P[E-R PV1 U SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 9868 East Hazelton!avenue-STOCKTON CA 95205-6232 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR 114SPECTIONS EXPIBES 11 YEAR FROM DATE ISSUED JOB,kDDRESS .� ilk / S:- CI-r.,/ZIP 17 4wjCROSS STREET -'."N PARCEL SIZE LAND USE APPLICATION If m cn � I� PHONE �a! - J OWNER WNER I'IAME J �/'-� A , /L�^� C r� +� n OWNER;=.DDRESS I �J � O W �1�G 2 �- CITY/STATE/ZIP / / /4 C CONTRACTOR i /� �yy�/� C")E'ez PHONE,;O!� CONTRACTOR ADDRESS (85 U L 350 CITY/STATE/ZIP �/'G [� (� l)�2 7 SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CirlISTATE/ZIP r LICENSE F,C-57 ❑ C-6'I ❑ D-09 ❑ Other NUMBER EXPIRATION 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 If different from Owner: Water System Name on ac Name or Phone Number TvPE OF WORK $eNew Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other 0 Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings, ❑ Geotechnical #of borings ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair ❑ New Puma ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing WELL CONSTRUCTION ' Drilling dlethod Mud Rotary ❑ Air Rotary ❑ AugerCable Tool ❑ Push Point ❑ Other Proposed Well Depth A -0 ft Excavation /.� in diameter ❑ Open Bottom ❑ Gravel PacldGravel Size in diameter ❑ Conductor Casing in diameter / Conductor Casing Depth fl Well Casing Diameter-6-- in Thickness/Gauge/ASTM Sched 4M- -I ❑Steel Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth. Neat Cement(94 Ib bag/540 gal water) Sand Cement (V _ 7i sack mix17 gal water ❑ Bentonite(20%solids) ❑ Other 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 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 WITI-1 THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT.1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. lye IM TOURADVANCENOTICE REQUIRED FOR INSPECTIONS 4 SIGNED TITLE o� �� DATE O _4-1 N P 4 i M E N T Xup,S O �L/QV 1r—KL�,II�j� Application Accepted By Date !/ V Area Employee ID#��/r^�`�/J Grout Inspection By Date SPECIAL Well Permit Pump Inspection By Date WAIVER Received R Soil Boring inspection By Date Constructed We Depth "� ft COMMENTS 2-�S '•- PE SC Received ecks' Amount Permit/ Codes Info By ash Remitted Date Service Request # Invoice# Well ID# 0 l 3 7Y - J 1-2Vkt W W'' END 43-00 WELL/PUMP PERMIT 8/04/08