Laserfiche WebLink
WELL I PUMP PERMIT <br /> &AN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER Aue 3"FL-STQeKTor4 CA 95502 -(209)461-3420 <br /> NON-REFUNDABLE PE IT CAL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR PROM DATE ISSUED <br /> I jolt ADDRESS 5962 DIVISIONrv"& AZIf CIT,., MANTECA _ <br /> .RIVERS Rn. �' tv <br /> CROSS STREET 1 f_S_1'�I.__-E. OF T 1r1 Q APN - PARCEL SIZE s3� LAND USE APPLICATION N yt to <br /> OWNER NAME MIKE COLEMAN PHaNL 993-2493 <br /> OWNER AonRLSs- 1212 RIVER PARK CT. turrysTATtair MODESTQ CA 95351 <br /> CONTRACTOR KENNINGS EROS. DRILLING CO. , INC. PRONB 545-1165 <br /> CONTRACTOAADnREss 3525 PELANDALE AVE. CITY/STATPJZIP MODESTO, CA 95356 .� <br />+I SUBCONTRACTOR PRONE _ <br /> r SUBCONTRACTOR ADDRLSS_ CffY/STATFJZIP t1LJ <br /> 410ENsr )M-57 0C41 1 0 D-09 0 Other NUMBER 9 R 1" EXPIRATION DATE <br /> GEOGRAPHICAL INFORMATION: Coordinates X y TowBshly^ Range Sralon_ <br /> INTENDED Use X01 DomesticlPrivate ❑IrTigationlAgricultuml ❑Industrial 0 Water Quality Monitoring G Soil Samp]ineCharocieriaation <br /> ❑Public water System rJ <br /> 1f diffaeM f— nor: ata yecM sex -4-�C�on-7sme`ur <br /> TYPE OF WORK d New Well ❑ReplaeernmL well 0 Well AlteratiDnIModitication ❑Test Hole ❑Other C' <br /> O Monitoring We l(s) N of wells ❑Soil Boring(s) a orbannp M Ocoteehnical a of boom <br /> ❑Well Destruction O Out-OF-Service Well ❑Out O&Service Well Renewal <br /> 0 New Pump O Pump Replacernut 0 PuTe Rcppir 13 Crea-Conneefion Repair --•� <br /> WELL CONSTRUCTION f�( <br /> Drilling Method M Mud Rotary 0 Air Rotary ❑Auger 0 Cable Too] O Push Point CI Othtr <br /> Proposed Well Depth &KI R Excavation 1 t4_in diameter 0 Open Bottom 0 Grivei Pack I Gravel Size in diamelM <br /> 0 Conductat Casing in diameter / Conduelor Casing Depth ft <br /> Well Caning Diameter 8 in ThicknessfGougGASTIO Sched 160 ❑Steel DX.Plaatic ❑Stainless Steel 0 Other .� <br /> 1 Grout Seal Depth1 Q88 ft R Neat Cement(9f IAIwg/J-1Qgn1 water} 13 Sand Cement •Truk mit!7 gal water <br /> 13 Bentonite(201/a solids) f3 Manufacturer Spec%solids % Name_ CI Speen on File O Sptxa Subminod <br /> Grout Placetnenl Method 1l Pumped ❑Free Fall ❑Other_ ❑Retatdaot/Acceferaw(name) <br /> PEDESTAL InstalledBv ❑Driller IXPumPContract'or ❑Other <br /> 13 Concrete PedeataL Dlmenalons: Width_ h Lengrh_fl Thick in Q Clarltty Box O Stove.Pipe <br /> PUMP ❑Submersible 0 Turbine ❑Other HP_ Pump Stl B Standing Water Level fl <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE 1N ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS, AND RULES AND REGULATIONS I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS, c <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS (' <br /> SIGNFO SQ31r L8 •SUPERVISOR DATE I-14—O5„„� <br /> P ` <br /> i <br /> I Ll <br /> V. <br /> f TA <br /> ;M VEW <br /> 5 <br /> ] M <br /> ca <br /> i <br /> DEPARTMENT USE O LY _ /(J <br /> Application Accepted BY "Z7-t"� ' � Date I 9 ��S Area ',71 fimpk*=ID# �7 <br /> I Grout lnspectior.BYred.' t; Daoer[/,j 13 SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received 7 <br /> Destrvcrian lmpS,ctwrr By Date Constructed Well Depth 4 <br /> I COMMENTS <br /> PI: SC ReceivedCher Amount Dau InvohN:q Well]DO <br /> Codes Info H nth Remitted ServieeR ueatA <br /> a EHD et-0Laah <br /> arena WELL PUMPPERMIT <br /> r <br />