SU0005291 - Laserfiche WebLink

Home Browse Search

WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH dE�,HENT 304 E WEBER A,-,"'FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED a 3 y g O's -T',�,�� s33 T JOB ADDRESS l{�, CITY/ZIP �/L L� a CROSS STREET 1 +�S 1 1" n APN 2 " © 3 I oPARCEL SIZE �9�)� c/ X OWNER NAME B OV Z.4 PHONE R Z 3— F / CJ K OWNER ADDRESS 4 S -T�N/y&-/`r Rz CITY/STATE/ZIP /r/GL4 �/ e-z1- 9-533 G N CONTRACTOR �_.� {� �, /�G�/f / f�i" N G PHONE CONTRACTOR ADDRESS 1 /�/ / / cc ` - CITY/STATE/ZIP "X SUBCONTRACTOR PHONE O SUBCONTRACTOR ADDRESS ) CITY/STATE/ZIP (•^ LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER 6 6Z 73Z EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USEDomestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ' ❑Public Water System If different from Owner: Water System Name ontact ame or one um er I TN'PE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modi ti cation ❑Test Hole ❑Other number of wells number of borings number of borings 11 Monitoring Well(s) ❑Soil Boring(s) ❑Geotechnical ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pum ump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION 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 (;D ❑Conductor Casing in diameter / Conductor Casing Depth tt �i- Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other n Grout Seal Depth ft ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cement suck mix/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 ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width ft Length tt Thick in ❑Christy Box ❑Stove Pipe PUMP ,R-Submersible ❑Turbine ❑Other HP Pump Set t Standing Water Level --A 15 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 tt Sealing Material ❑Neat Cement(94 lb bag/5-l0 gal water) ❑Sand Cement suck 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 1 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 LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION S. MI M 4 DVANCE NOTICE REQUIRED FOR 1 1 PECTIONS- PLEASE CALL(209)953-7697 SIGNED TITLE / G�Z��' DATE +1 0 - 1, r - . e" F u � u 1C.',�At SH N1 - - - - - - FN RoM DEPARTMENT US ONLY Application Accepted By l]� D O �-w Date - - C Area a, Employee ID# '"(� I_ 3 Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date � ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC Received C Check#/ Amount Date Permit/ Invoice# Well ID# Codes Info By as Remitted Service Request# Ll 380 0s0 n2-2— -c 7114D3 _5RO034 419 EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002