SR0042190 - Laserfiche WebLink

Home Browse Search

It II WELL 1 PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES I YEAR FRAM DATE ISSUED u} JOB ADDRESS _ l�Sa E HOiGI) !/JS•�__- - �.. _ CITYIZIP T Tz N CROSS STREET12DUO A4tT H5LL APN O-4O"'09 O I o (r PARCEL SIZE LAND USE APPLICATION# tz n rn OWNER NAME PHONE ZZ -4/��— 80& n OWNERADDRESS 1'Q } 2 CITYISTATEIZIP CA KZ67 CONTRACTOR At�t.�4L E,��1K J�� DSSp(� c,' L PHONE CONTRACTOR ADDRESS 3y/d f}gje2,a4 L,�1AEjk" S[JIT'Z�,0 CITVISTATEIZEP 7 O/l> SrZj A SUBCONTRACTOR RLI- — jGlf L A�D PC PHONE LCA LS'4 ?jjZ SUBCONTRACTOR ADDRESS '.p Y CITY/ST 9i,Z [y LICENSE JCC-57 ❑C-61 ,I; ❑D-09 ❑Other .. NUMBER O Z pOt XPIRA ODA GEOGRAPHICAL INFORMATION: Coordinates X a Y7d�vS�sFf#pl��llI, i�M� eEy INTENDED USE ❑Domestic/Private '❑Irrigation/Agricultural ❑Industrial ❑Water Qua RiDe4@9 CMP1 St&dir�CMpct.gAz' 11 iA !lIaL1G GLJ ❑Public Water System I If different from Owner: Water System Name by i - one440althM iSion I .I 1lJ!I --. TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other n I ( of borings —aof borings❑MonitoringWell(s) -#ofwells ❑Soil Boring(s)(s) Geotechnical ` Cl Well Destruction ❑put-Of-Service Well El Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Crass-Connection Repair WELL CONSTRUCTION . Drilling Method ❑Mud Rotary 11 ❑Air Rotary JM Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth�j I ;ft Excavation_ 7 in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing ` in diameter / Conductor Casing Depth ft I Well Casing Diameter iq Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth k'5- ft It Neat Cement(941h hag/5-10 gat water) ❑Sand Cement sack mix/7 gal water i ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted r Grout Placement Method ❑Pumped ❑Free Fall ®Other 7rfj MM 1 JE ❑Retardant/Accelerator(name) PEDESTAL Installed By Er ❑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 WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other el t Tot pt Depth Pe rat f I aEplete l ❑N e" 941b S- gal wa ) ❑San ement ck mi 7 gal w r entonit lIe C B /0 s`` d nu turer S %solids ame ► S e pecs u mi I Place ❑P edl e ❑Other IFC w1 roo Cap below grade ❑ p e to Existing rfa Pad 1 HEREBY CERTIFY THAT 1 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE '.7� i�� E/Vt DATE �- IV I ry.. -- �ltU E EIGHT.. MIIE a D lies-sT 700 -Aw a -FLKltORH�C@'!l4TR1„ r o i S cIN' r CLUB �r Gxc :" b a5, i .Pta /�O a Ir I� fti r k ai C, o xsTGxe l rAlldAr KARLE17E _RD !G �Cr f:_ rA ie+R t — �-.—�u 952 O rlGxs Trx oeea N[u wfsri ulxUJunEAR xl' ' oCPW11RE x IryR OR t If Ali:OR $' Ap NR GL g SfJXI°1 0 • y�j c PWSER•AYa __a. 11U GOINGS � r ei E xs 71:LEB RON R pR 4 Mtu_ on I cT CRt��q WY 'I U�Si Rlx°Yr rtDEPWRTMENT USE ONLY Application Accepted B v . ;i PP P Y Date . Area Employee ID# Grout[iis ection'B' -''- p y llate ❑ SPEC[A'G WelIP6I rnj - " Pump Inspection By Date ❑ WAIVER Received ` Destruction Inspection By t Date Constructed Well Depth ft COMMENTS .F PE SC Receivedhe ! Amount Date Permit! Invoice# Well ID# Codes Info B ash Remitted Service Request# 3�2 rsv CID J311 vt> 5f�-00 ,7-t Cf 0 EHD02-OD6 12!22120/2003 MASTER WATER WELL PERMIT I I��