Laserfiche WebLink
WELL / PUMP PERMIT <br />t• SAN JOAQULN COUNTY ENv'IRONMENTAL HEAt.TH DEPARTMENT 600 EAST MnLN STREET -STOCKTON CA 95202 - (204) 46$3429 <br />FROM <br />JOB ADDRE.SS >" LU�PJC) 56W ( Crrvalr ?/'j.,X b% T0 J <br />CROSS STREET I OAF APV ,�.•�+� ;/ V IOI' <br />PARCEL Slze <br />OWNER NAMEPHONE <br />OWNER ADDRESS CITY/STATE/ZIP <br />CONTRACTOR All, <br />p /' J `j .. � PHONE — <br />CONTRACTOR ADDRESS _(O70�F Hu.i ClE/IL <br />'rY/STATP 6L4—a-rlv—gl <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESS __ CITY/STATFMP _ <br />LICENSE ❑ C-57 1 ❑ D-09 ❑ Ocher NI.RMY ExPIIL1TtoN D.NTE _ <br />GEOGRAPt11CALINFn ar.%tin- r—do...e.a Y <br />INTENDED USE ❑ Domestic/Private ❑ hTigation/Agiicuitural ❑ Industrial 0 WaterQDality, Monitoring ❑ Sol! SamplinipCharacteritatioo <br />❑ Public Water Syys5tem <br />If <br />d� z nnm Ow Wmtt S)mm Vame Comacr Varve or Ph— Vumba <br />..rc u1 .rvae u Nm weu u xeplaccment Well 0 Well Alteration/Modification ❑ Test Hole ❑ Other <br />❑ Monitoring Well(s)__ numbrr°t�us ❑ Soil Boring(,)--orbodoas ❑ G.Wheical oumherotburiogs <br />❑ Well Destruction O Ont-Of-Scrvice Well ❑ Oul-Of-Srnice Well Renewal <br />WELL CONSTRUCTION <br />Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger O Cable Toot ❑ push point O Other <br />Proposed Well Depth R Excavation in dianxter <br />0 Open Bottom ❑ Gravel Pact / Gravel Site in diameter <br />13 Conductor Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter in Thickness/GaugeJASTM Schell <br />❑ Steel ❑ Plastic ❑ Smirdess Steel ❑ Other <br />Grout Seal Depth it O ,Neat Cement 1941b bag/5-10ga1 nrtter) <br />❑ Sand Cement sack mix/ 7 gat water <br />❑ Bentonite (2(M9; salids) ❑ Manufacturer Spec % solids _ % <br />Name ❑ Specs on File ❑ Specs Submitted <br />Grout Placement Method ❑ Pumped ❑ Frcc Fall ❑ Other <br />❑ Retardant / Accelerator (no=) <br />PEDE5r1L Installed By ❑ Driller ❑ Pump Contractor <br />❑ Other <br />❑ Concrete Pedestal Dimensions: Width (i. Length_ <br />_ <br />ft Thio in ❑ Christy Box ❑ Stove Pipe <br />Pu\1P Submcniblc ❑turbine ❑Other _ HP <br />Pump Set tmft Standing Water Level !"� n <br />11'ELt. DEStRU('1JON ❑ Open Bottom O Gravel Pack ❑ Uncased <br />❑ Other <br />Well Diameu:r in Total Depth_ ft Depth to Water <br />ft ❑ Casing to be Perforated from ft to ft <br />Scaling Material ❑ Neat Cement 041b bag 15-10gal mater) ❑ Sand Cement <br />sack mix; 7 gal water O Bentonite Pellets <br />O Bentonite (20% solids) ❑ Manufacturer Spec % solids _ % <br />Name ❑ Specs on File ❑ Specs Submitted <br />Placement Method ❑ Pumped ❑ Free Fall ❑ Other <br />❑ Complete with Mushroom Cap ft below grade <br />O Complete to Existing Surface Pad <br />- - o,� ArlLrl,AIIV.V A -N. 1.1 THE WORK WILL BE DONE LV ACCORDANCE WITH SAN <br />JOAQULV COUNTY ORDINANCES, STATE LAWS, <br />AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT ANPI ACTIVE VOTH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM LV COMPLIANCE WITH ALL <br />WORKERS C N <br />-� NOTICE R OCIRED FG ' <br />t <br />TITLE DATE DATE C <br />aL:P 192016 <br />IAL HEALTH <br />RV►CES <br />Application Accepted By, <br />Grout Inspection By. <br />Pump Inspection By, <br />Destmction Inspection By. <br />COMMENTS <br />EP.4TtTVMNT USE N <br />Date Area 12 I v t Employce 10# <br />S�7 Dau:13SPECIAL. Well Permit <br />i <br />llaix Y1JJI ❑ ER Received <br />Dale_ I ` Constructed Well Depth _ It <br />!yen Fentllt and DKiardt1—dne <br />9/I ]!2007 <br />MINA <br />�'S1t7S7�4!•1•+ <br />!yen Fentllt and DKiardt1—dne <br />9/I ]!2007 <br />