SU0006895 - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP-.n`WfMENT 600 EAST MAIN Shwtt�T-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE I PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS \ C� �� 1��-� j�/_� CITY/ZIP l 2-C'� r^ S,1 D CROSS STREET , l `L� 7 APN C��S"–(HL)—,3 y PARCEL SIZE��I'S'LAND USE APPLICATION22#,a�l'� -070C--5 ��°�` OWNER NAME t PHONE -33LA ` OWNER ADDRESS l% w - 1rJ {/�CITY/STATE/ZIP ) CONTRACTOR PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE 0 C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE Domestic/Private C Irrigation/Agricultural Industrial 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 O Well Alteration/Modification Other ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings -, Geotechnical #of borings .pOut-Of-Service Well ❑ Out-Of-Service Well Renewal Cross-Connection Repair ❑ New Pump Pump Replacement ❑ Pump Repair ! Raise Well Casing WELL CONSTRUCTION Drilling Method ❑ Mud Rotary Air Rotary ` Auger Cable Tool Push Point i Other Proposed Well Depth ft Excavation in diameter iJ Open Bottom Gravel Pack/Gravel Size in diameter C Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑ Steel Plastic Stainless Steel Other Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) Sand Cement sack mix/7 gal water Bentonite(20%solids) ❑ Other Z, Grout Placement Method E Pumped ❑ Free Fall L-1 Other Retardant/Accelerator(name) PEDESTAL Installed By Li Driller L Pump Contractor i Other Concrete Pedestal Dimensions:Width ft Length ft Thick in Christy Box Stove Pipe PUMP Submersible Turbine -1 Other HP Pump Set ft Standing Water Level ft 4- 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 1 AM )N COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM24 OUR DVANCE NOTICE RE cIRED\FOR INSPECTIONS f t NED R �) TITLE �` ��\ ti Y� G _ DATE I O IL L— Ul C t1 NIR N N y{ AL DEPARTMENT JUE ONLY Application Accepted By Date �l /3 6 12" Area Employee ID# 5'� Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date - WAIVER Received Soil Boring Inspection By Date Constructed Well Depth ft COMMENTS — �7C��S.S PE SC Received Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info B Remitted Service Request# 43&q 179 230 V l oo. EHD 43-06 WELL/PUMP PERMIT 8/04/08