SR0034725 - Laserfiche WebLink

Home Browse Search

WELL 1 PUMP PERMIT /o 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 FROM DATE ISSUED J08 ADDRESS AMW CITYIZIP 7y /(J ✓ l M — � a CROSS STREET /�`� /{ - APN -[� PARCEL SIZE OWNERNAME ��-�+ � - _ ! 4 `�-�1� PHONE OWNER ADDRESS r i CITY/STATEIZIP i� CONTRACTOR zwA PHONE CONTRACTOR ADDRESS Z+e)Y—j- CITY/STATE/ZIP SUBCONTRACTOR 1/ Q - PHONE ./'. ''' ` SUBCONTRACTOR ADDRESS F ! / �r � CITY/STATE/ZIP /Ilk F�4-;�`rf�J LICENSE -57 -61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE omestic/Private ❑lrrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterizalion ❑Pubhc Water System ^� + Kdifferent from Owner: Water System Name CDntwl Name or Phone umbir TYPE OF WORK,)RjJew Well ❑Replacement Well ❑Well AlterationlModi Fcation ❑Test Hole ❑Other number of wells number Df borings numher of horinyn C3 Monitoring Well(s) al D Well Destruction ❑put-Of-Service Well ❑Out-Of-Service Well Renewal-&14fi ew Pump C]Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTR CT ON Drilling Methodlud Rotary 0 11 Air Rotary ❑Auger El Cable Tool 13 Push Point El Other Proposed Well Depth � Excavation /2 t in diameter 0 Open Bottom ---4;r1ravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter ! Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Schell--e-L-f l ❑Steel Aolastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94 16 hug/5-10 gal wafer) ❑Sand Cement suck mix/7 gal waterro ❑Bentonite(20%solids) VManuracturcr Spec%solids % Name ❑Specs on File ❑Specs Submitted ? Grout Placement Method Arlmped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller Acump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length A ft Thick in El Christy Box ❑Stove Pope PUMP ubmersible ❑Turbine ❑Other HP Pump Set X00 ft Standing Water Level ft WELLDESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from 11 to ft Sealing Material 13Neat Cement(94 1h hug/5-10gal water) ❑Sand Cement sack mix/7 gal water 13Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑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 ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS, I ALSO CERTIFY THAT MY REQUIRED LICENSE 15 CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINI WUM.,,Ulk CE NOTICE REQUIRED EOR INSPECTIONS—PLEASE CALL(209) 953 769SIGNEDTITLE r+ DATE / r a RJ n 1 s i, �rI hn� NVi`i r }} DEPARTMENT USE O'NLV _)) !�J Application Accepted By V I! r'" r' Date 0 ) Area Employee ID## 0 0 ( Grout Inspection By Date C� n- ❑ SPECIAL Well Permit Pump Inspection By c-r „��- _ Date )i-z3 0-1 ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received Chec> Amount Permit/ Codes Info B Cash Remitted Date Invoice WeIIID# EHD 43.02-006 MASTER WATER WELL PERMIT