SU0003460 - Laserfiche WebLink

Home Browse Search

cei yd , y,OO,LL / PUMP PERMIT � / ,AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE 3'4 -STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED Jon Aitpiwss �? /T) � n �ON 7% 149k)e.✓ rW- CITY/ZIP !fit\ 9x36,6 CROSS S'I'REk:I' L/es>' 4`tI� c[ c �S e) T PARCEL SIZE / /! � APN OwNERNAME � r,/J 1� .e-/• �J/n OWNER ADDRESS oN Y -1,741 ev V CITV/STATE/ZIP •/ l/,,aix�x �f'S 3G CONTRACTORrS'�I PHONE CONTRACTORADDRESS /y?1 ,6Q5 'dW CITV/STATT/Z rl 101h,01 1 . 42 SUBCONTRACTOR SUBCONTRACTOR ADDRESS e oe� LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinaes X Y Township Rang! Section r TENDED USF. 13Domestic/Private Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Chameterizatlon ❑Public Water System If din rem fnnn o,,.,: Wal,,Syvann N..w Contact Nznrc or Phoat Nur TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Mohlicalion ❑Test Itole ❑Other ❑Monitoring Well(s) nuanI,orof.dN 11Soil Boring(s) nnmbo,Obadnge ❑Geotechnical number ofbodnae ❑Well Destruction ❑Out-OfService Well ut-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth it Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth R Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth R ❑Neat Cement(94 Ih bag/5-10 gal wafer) ❑Sand Cement sack mix/7 gal water ❑Bentonite(2(r/solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File 0 Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width_ R Length it Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set R Standing Water Level tt WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Tolal l)Lpth R Dcpth to Water R ❑Casing to be Perforated from it to It Sealing Material ❑Neat Cement(94 11)hag/5-10gal wafer) ❑Sand Cement .rack mix/7 gal water ❑Bentonite Pellets ❑Bemonile(20%salids) ❑Manulilcturer Spec%Solids_% Name 13 Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other O 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 ALCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MI 24 HOUR AD NC NOT E REQUIRED FOR INSPECTIONS—PLEASE CALL(209)953 7697 SIGNED TITLE //Le✓/ DATE �/ D tf 4 c v Ifl N E e o — V L O/ DEPARTMENT USE NLY q'J7 Application Accepted By mDate_ t 2G Area �/� Employee ID# 43-1 1 Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By _ _ Dale �� ❑ WAIVER Received Destruction Inspection B Da Constructed ell Dep ft COMMENTS P SC Received Cheek#/ Amount Date Permit/ Invoice# ell IDN Codes Info By. ash Remitted Service Request# 43-77 05-0Sc,.ca 1 00 '-3 LG EIID43-02b05f, MASTER WATER WELL PERMIT