SU0003902 - Laserfiche WebLink

Home Browse Search

1d64-4 � WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH M1IEN-1304 E WEBER41a w e"FI.-S OCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED to JOB ADDRESS 6801 South Mobley Road CITY/ZIP Stockton 95215 a Gawnp185-120-02 } p CROSS STREET APN PARCEL SIZE LAND USE.APPLICATION# In rn OWNER NAME Anita XX211fXX91X§EX 1§X Slicton PHONE 899-2444 OWNERADDRESS 22349 Milton Road CITY/STATE/ZIP Farmington, CA 95230 CONTRACTOR Clark Well , Inc . PHONE 209-462-7676 CONTRACTOR ADDRESS 2024 East Charter Way CITVISTATEIZIP Stockton, CA 95205 SUBCONTRACTOR None PHONE SUBCONTRACTOR ADDRESS CITYISTATEIZIP LICENSE 0C-57 0C-61 0D-09 ❑Other NUMBER 371560 EXPIRATION DATE 04/05 GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section O INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterizadon ❑Public Water System If different from Owner: Water System Name Contact Name or Phone Numbcr /,- TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other U] ❑Monitoring Wells) #of weIIS ❑Soil Boring(s) a of borings N of borings ❑Geotechnical ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair (Cross-Connection Repair 1> WELL CONSTRUCTION ref, Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter 1 Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth 11 ❑Neat Cement(94 1h hag/5-10 gat water) ❑Sand Cemcni .tuck mLr 1 7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller Cl Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe T� PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(941h hug l S-10gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite 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 HEREBYRTI FY THAT 1 E PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN C NTY ORDINAN E S TE LAWS AND ES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT A CTIVE WIT T E ALIF CONT CT IRS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS C ENSAT L S. NCE NOTICE REQU.IRED FOAINSPECTIONS SIGNED TITLE r+ ' DATE 1 b IL 21-1 7 '11k2f V +; I Ll L Ii �r DEPARTMENT USE NL Application Accepted By Date t Area 11- Employee IDA S Grout Inspection By i Date / ❑ SPECIAL Well Permit T CIZ{f5�tspecrl By Date ❑ WAIVER ReCeived Destruction Inspection By Date Constructed Well Depth ft COMMENTS /1&10�97 /i5 PE SC Received Checklf Amount Dare Permit/ Invoice# Well IDN Codes Into ash Remitted Service Request# c�I 0 t, -3a S,ecO -70�r7 ac El C� Sy� .Q 3 , �~ J MASTER WATER WELL PERMIT 1 u2zrz0o 1 L