SR0081403 SSNL - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3a"FL-S'TOCKTONj&2tt79 68- IO NON-REFUNDABLE PERMIT CALL 209 953-7697FOR INSPECIIONS EXPIRES I YEAR 7E I' UED --7IRC) JOB ADDRESS `I,J !d/�L�� CITY/ZIP _ D CRossSTREt:'T ISI rvv/J/N APN ME PARC��ErI+.SI:tE 4 OWNER NA /c./^/�.R./ ry�C� PIIONF-�J l v , 1 0 I`y OWNER ADDRESS �\ _ CTCYISTAT'EIZIP— CONTRACTOR PHONE ZL! 7 2-5- CONTRACTORADDRESSSS _r CITV/SIw'I"L(P �` O SUBCONTRACTOR L72Y " !� ! y�/YFsY _ PHONE SUBCONTRACTOR ADDRESS �7CITY/STATE/ZIP C LICENSE C-57 0 C-61 0 D-09 O Other :NUMBER S+/7] E%PINATION DAYF. CEOCRAPHICAL INFORMAL"ION: Coordinates X Y_ Township_ RAnze Section /MCNU6u USE,�Dornoslic/Pnvate D trrigarioNAgriculturat 0 Mdustoal O worer Quality Monieorin6 t7 Soil SamplinglCharocuri7Ation t O Public WaterSy}^,tem If ddTe+ant from fy o -" mer ystem nine --�T^nieci fTme�n+l'�wu-A � TYpr OF WORK XNew Well 0 Rrplacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other O Monitoring Wells °umbo`°r"its ❑Soil Burin s numbarorboonas ❑Geotechnical number ofb.'ina. O Well Destruction ❑Out-Of-Service Well 0 Oul-06Service'JVe11 Renewal ❑ ew Pump ❑Pump Replacement 0 Pump Repair O Cross-Conncnion Repair WELL CONSTRU T Drilling Method Mud Rotary O Air Rotor)- O Auger O Cable Tool O Push Print Q Other Proposed Well Dcpth-:a�4—ft Fxcaystioo in diameter ❑Open Bottom Gravel Pack/Gravel Size_ in diameter I O Conductor Casing_ in diameter / Conductoi Casin Depth _11 Well Casing Diameter,�in Thickness/GauB�ASTM Schad l I-j� O Steel ❑Stainless Steel 11 Other_ Grout Seal Depth-1 _J!Il Neat Cement(941h hag/5-10gul woler) Mand Cement_ .trick rnir!7 gal water Q Bentonite(20%solids) O Manufacturer Spec%solids_ . Nance__ O Specs on File O Specs Submitter) Grout Placement Method umped O Free Fall 0 Othcr__ O Rctrrrdam 1 Accelerator(namc)_ PEDESTAL installed By AO(iller O Pump Coturacior Q 0 Other O Concrete Pedestal Dimensions: Width _tt length C A Thick�in 0 Christy Box ❑Stove Pipe 4 PUMP $4ubmersible O Turbine O Other___ HP-__T Pump Set fl Standing Water Level ft II WELL DESTRUCTION ❑Open Bottom 13 Gravel Pack ❑Uncased Cl Otlref Well Diameter_—in Total Depth R Depth to Water 0 Q Casing to be Pertbrated from flto n Sealing Material O Neat Cement(941h bag/5-10gul wuier) O Swid Cement— ,suck mix 17 gat water O Bentonite Pellets D Bentonite(201/solids) ❑Manufacturer Spec%solids °res Name—,Y _Y O Specs on File 0 Specs Submitted Placement Method O Pumped 0 Free Fall 0 Other Q Complete with Mushroom Cap 0 below grade O 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. IMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS c SIGNED TITLE Gc ICI DATE •nI i DEPARTMENT USPONI# �7 Application Accepted By _ Date-7 dL^ Area G-1 Employce IDN Grout nspection By �._ Date 2 O SPECIAL Well Permit Pump Inspection Uy ❑ WAIVER RCCCIVCd Destruction Inspection By__J _ __ _ Dare_ _ Constructed Well Depth it COMMENTS��Q,Q— PE SC I A unt Recelvcd Date InyaiceN well IDA Codes JON Remitted By Service Request // 2' 05-.0 S?J aLt C`X13 EllD 43.02-006 MASTER WATER WELL PERMI'l 5!"!2002