SU0005605 - Laserfiche WebLink

Home Browse Search

_ WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH RTMENT 304E WEBE' S3"FL-STOCKTON CA 95202 - (209)468.3420 NON-REFUNDABLE PERMIT SCALL 204 953-7697 FOR INSPECTIONS �-e$PIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS ��f'�C 1 � \CO��O i M CITY/ZIP �C �1 g� Oi7�/ N (� CCC!!!! brc� l. y OA� CROSSSTREET ,� APN� 77 266 PARCEL SIZE er 30 OWNERNAME "PC_ \ �1.� r�.r�� QPHONE OWNERADDRESS'� 0 �03L -L� CITY/STATE/ZIP CONTRACTOR L1 PHONE CONTRACTOR ADDRESS CITY/STATE/ZIP SUBCONTRA '�CTOR n `t� `� PHONE , Z SUBCONTRACTOR ADDRESS \�+ \ A CITY/STATE/ZIP `y\ r` I LICENSE C-57 C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section INTENDED USE Dc mcstic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization V` ❑Public Water System Ifdifferem from Owner. Water System Name Connect Nome or Phomc Numtrer tf TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) numberarwelis ❑Soil Boring($) numberofbonngs ❑Geotechnical numberofborinyy ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal V• ❑New Pum )0ump,Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary O Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth 11 Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth R Well Casing Diameter _in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel O Other Grout Seal Depth B ❑Neat Cement(941b hag/5-10 gal swrler) ❑Sand Cement sack nial7 gal water ❑Bentonite(20e/Solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Grout Placement Method O Pumped Cl Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width_ H Length_fl Thick in ❑Christy Bax ❑Stove Pipe PUMP Submersible ❑Turbine ❑Other HP�Q Pump Sete H Standing Water Level �a� 11 WELL DESTRv ION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth tt Depth to Water D ❑Casing to be Perforated from ftto R Sealing Material ❑Neat Cement(94 lb lag/5-10 gal 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 O Other ❑Complete with Mushroom Cap tt below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT I 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 LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTLCE REQUIRED FOR INSPECTIONS SIGNED5n� 0. TITLE A�Y , DATE T D 004 N OUNTY S TAL TMENT EPARTMENTU , / Application Accepted By 6� r ale Area �// / Employee ID# J 777 r I�j Grout Inspection By _ Date 11 SPECIAL Well Permit ��TTTT 1 Pump Inspection Date ❑ WAIVER Received Destruction Inspection By Date Constructeedd�Welll Depth '�J ft COMMENTS�.T�3,1, F� efCWIrIP1G/ C / �-� 'S iE J �C2r A�JBt 1.il rs✓AC6 PE SC Amount Check# Received Date Permit/ Invoice# Well IDN Codes Info Remitted ash By Service Request# AW e2 173 �1L51D EHD 43-02-006 MASTER WATER WELL PERMIT snrzDD2