SU0005772 - Laserfiche WebLink

Home Browse Search

3A WELL / PUMP PERMIT - 1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH ARTMENT / 304 E WEBS J$30.°FL-STOCKTDN CA 95202 - (209)466-3420 NON-REFUNDABLE PERMIT CALL Z �c�IO-�1071 VtJK IN C/ SPECTIONS EXPIRES l YEAR FROM DATE ISSUED JOB ADDRESS l-+[ —Man i Rd CCTV/ZIP D � r CROSS STREET { I /� D p APN ► jIi`� Z ��Z Z RC� t E - OWNER NAME V �y�(rS o i iL bevy d en ��G �� 1 i �. PHONE OWNER ADDRESS Gl or R Oil C `i�l11-CITY/STATE/Z[P CONTRACTOR _V- - PHONE e7- 15 `15 CONTRACTOR ADDRESS �'z5 / „ Y��j�' CITY/STATE/ZIP '� � 'r— II SUBCONTRACTOR i PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE -57 ❑C-61 ❑D-09 ❑Other NUMBER i%--TLZZ3n EXPIRATION DATE :k CEOCRAPHICAL INFORMATION: Coordinates X Y T INTENDED USE ❑Domownship Range Section `S estic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring _ ❑Soil Sampling/Characterization ! ❑Public Water System I If different from Owner- aterystem ame Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement We]] ❑Well ❑Test Hole El Other ❑Monitoring Well(s) number of wells g soil Bs _9 ❑Geotechnical number of borings number of twrings i'� Boring(s) ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump I❑Pump Replacement ❑Pump Repair D Cross-Connection Repair -11111M CONSTRUCTION Drilling Method ❑Mud Rotary D Air Rotary ager ❑Cable Tool ❑Push Point ❑Other Proposed '10 / �~ p Depth 1 ft Excavation (O in diameter ❑Open Bottom ❑Gravel Pack I Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft �' Welt Casing Diameter in" Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel El Other Grout Seal Depth s ft ❑Neat Cement(94 lb hag/5-10 bag wager) ❑Sand Cement suck rnrx!7 gal water fl Bentonite(20%solids) .❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall O Other p ❑Retardant/Accelerator(name) 1 PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal .Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set fl Standing Water Level ft 41101W.DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter % in Total Depth ft Depth to Water ft ❑Casing to be Pertbrated from ft to R Sealing Material ❑Neat Cement(94 Ib bag/5-10 gal wafer) ❑Sand Cement sack rnix/7 gal water Bentonite Pellets 11"� �kyd+r`i ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Apfl ed Placement Method ❑Pumped ❑Free Fall ❑Other Complete with Mushroom Cap fl 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE ALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION L U 4,HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS �i StrNen JC - - - / DATE V/Z-r/7 _ - FEDORA WP _ - Rd. ROT RO. Ro. 0a NE z tga�' = Lo4EL p r i xr�r..r �• y 1 L...Jai me Ate , 4 �„. o RD' - - AV. sou IREs° `y*' 4 Z p t"7 E r :::1 ae ��j DE 41Mn 80-� qx..• �' `�" ._-. G� a t3: O 0, _ r00&'Reis CO.Px. r y ,� aye 1 S �-'-- � � I �o '��•D0.S REIS R0. t LATH- `:y#` Z 2 d 1® t O r ADP: 1aL11yt CCM.P Lro V w - ...-... � i l THOMSEH EL.'122X .. m zy i J Al. LOUIS r: q 1' ®f...__. _--. I f� `S` 1 c 1-1.3 < a 7 SITE PLAN r A ][Cation Accepted B Date '-L •'I- _Area _ Employee ID# �� b App� P y - -- Grout Inspection.By ;Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date C nstruc d W 1 Depth f COMM T ' r 17 Olt PE SC Amount h l Received Date Permit! Invoice# Well ID# Codes In Remitted ash By Service Request# 43.31 15-0 3Q !1 -8003091111 Q t{ EHD43-02-006 MASTER WATER WELL PERMIT if 5/7/2002 if