SU0003452 - Laserfiche WebLink

Home Browse Search

WEL PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTTI DEPARTMENT 1 304 E WEBER AVE 3"n Ft.-STOCKTON CA 9S _)(Z09)468-3420 NON-REFUNDABLE PERMIT CALL(205,•;,53-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 1, 7 Q� rye /�-- rn JOR ADDRESS c� O "`r� c >I' " ' CITYIZIP�?�C'KT� I� r^' y —rq QU�^ v CROSS STREET Q c APN 'I ` t !� PARCEL SIZE LAND USE A PrPLILLIICCAA/TIIO�N A t/ -] OWNER NAME �J lJ'-'rrGr4 r, �\ f 0— \J PRONE�E f r — �f�T� OWNER ADDRE&S < 'I!1 ' P::`=2 —/r v CITYISTATEIZIP f7 ��t� `� ' ��! CONTRACTOR L7 PHONE CONTRACTOR ADDRESS CITVISTATKIZIP SuRCONTRACTOA PIIONE. SUBCONTRACTOR ADDRESS CITYISTATFJZIP LICENSE 0 C-57 0 C-61 0 D-09 ❑Other NUMDE:R EXPIRATION DATE GEOGRAPHICALINFORMATION: COOrdimues X Y Township Range Section INTENDED Use omestic/Privale 0 IrrigationlAgriculturai ❑Indusiriai 0 Water Quality Monitoring 0 Soil SamplinglCharacter'szation 0 Pu lic Wal",.. ater Syystem 1rdiRerent fmm rlwna; alcr ysmm Name nntact ame or one um r TYPF.OF WORK 0 New Well 0 Replacement Well ❑Well Alteration/Modification 0 Test Hote 0 Other I k of boon 0 Monitoring Well(s) #orwe)IS ❑Soil Boring(S) k of boring 0 Geotechnical 0 Well Destruction ❑Out-OFService Well 0 Out-Of-Service Well Renewal 17 New Pump 0 Pump Replacement �&rnp Repair 0 Cmss-Connection Repair - WEi.'CONSTRUCTION Drilling Method 0 Mud Rotary 0 Air Rotary 11 Auger 0 Cable Tool ❑Push Point 0 Other _ Proposed Weil Depth R Excavation in diameter 0 Open Bottom ❑Gravel Pack/Gravel Size in diameter 1 ❑Conductor Casing in diameter / Conductor Casing Depth R Well Casing Diameter_in thickness/CaugUASTM Sched 0 Steel 0 Plastic 0 Stainless Steel 0 Other Grout Seal Depth R 0 Neat Cement(94 th hag/5-10 gal water) 0 Sand Cement .rack mix 17 gal water 0 Bentonite(20%solids) 0 Manufacturer Spec%solids % Name 0 Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall 0 Other ❑Retardant I Accelerator(name) PEDESTAL Installed By 0 Driller 0 Pump Contractor IJ Other 0 Concrete Pedestal Dimensions: Width R Length ft Thick in 0 Christy Box 0 Stove Pipe PUMP 0 Submersible 0 Turbine 0 Other lip Pump Set R Standing Water Level Il WELL DESTRUCTION 0 Open Bottom ❑Gravel Pack ❑Uneascd ❑Other Wcll Diameter in Total Depth R Depth to Watcr R 0 Casing to be Perforated from R to Il Sealing Material 0 Neat Cement(94 lb hag/5-10 gal wafer) 0 Sand Cement rcrck ml 7 gal water 0 Bentonite Pellets 0 Bentonite(20%solids) 0 Manufaclurer Spec%solids % Name 0 Specs on File- 0 Specs Submitted Placement Method 0 Pumped ❑Free Fall 0 Other ❑Complete with Mushroom Cap R below grade 0 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. IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE L[CENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION S. r NI UNI 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS ++� SIC.NT.D TITLE: --J'�L DATE J�r� r _ I DEPARTMENT USE LY Application Accepted By Date 0 Area Employee IDI Grout Inspection By Date 0 SPECIAL Well Permit /7 Pump Inspectio y Date , /� ❑ WAIVER Received Destruction Inspccti Date Constructed Wei fl C COMMENTS -Q --� `-� PE SC Received Chec Amount Date Permit/ Invoice Well IDA Codes Info By Cash Remitted Service Request 9 3 p ryb X37 El D41-a2-Oa6 MASTER WATER WE.I.I.PERMIT rntv±ml