FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTHMENT 304E WEBER " FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT �LL 209 953-7697 FOR INSPECTIONS VPIRES 1 YEAR FROM DATE ISSUED s'/L� ^� JOBADDRESSS l'�' Wcs�"Tut�nG" "� CITY/ZIP Loc L 1 Q<---) m T Y CROSS STREET �— APN ,O2, rJ — I Zd— O 1 PARCEL SIZE 7 cr p 11 / teaINA y OWNER NAME C 0.h AYI(12J Q ULa W IYt P (..O �/ M-Ai,. PHO1NE 2o9 334 rQr `9B OO �• OWNER ADDRESS �{r�(�-,/Ist{• Wim, cTurne-r P-cl /� 1 / ' CITY/STATE/ZIP WC1PI CM � LT� CONTRACTOR Y V n2t,-�L'Ace 11-0_1tTL- ZI, 14(SS O C, `'P1HONE 116 '3-7'2 CONTRACrORADDRESS 'y{3' 05L./'t\I V'%a uS�( 4A �I�V W CITY/STATE/ZIP W . S;r-C./ --LFA 95691 SUBCONTRACTOR V `t' � .QQLJP—k L�fL I W6t PHONE-au -m- {� tp1 QO SUBCONTRACTOR ADDRESS PO 12L0X 416 CITY/STATE/ZIP LICENSE YC'-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range_ Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Ow... Water SysmmlTame Contact Name or one um er TYPE OF WORKew Well ❑Replacement Well ❑Well Altemtion/Modification ❑Test Hole ❑Other 1114lltoring Well(s) '1- A:.�Y)t�lls ❑Soil Boring(s) numberofborings ❑Geotechnical oumberofborinp ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL g Method ID IQ�� C/I.Y�'✓ O.O�� Drilling Method ID Mud Rotary ❑Air Rotary IQ/Auger ❑Cable Tool El Paint ❑Other Proposed Well Depth It Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Sizein unneter ❑Conductor Casing in diameter / Conductor Casing Depth ft We11.Casing Diameter in ThickneW�G�auge/ASTM c ed 4a P�( )MC.❑Steel @' astic 13 Stainless Steel ❑Other Grout Seal Depth S tt 1p eat Cement(94/h hug/5-10 gal wafer) ❑Sand Cement sack rn4r/7 gal water ❑Bentonite(20%solids) ��❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped RIK.Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width R Length_ft Thick in ❑Christy Box ❑Stove Pipe 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 It ❑Casing to be Perforated from R to ft Sealing Material ❑Neat Cement(94 lb hug/5-10 gal water) ❑Sand Cement sack mix 17 gal water ❑Bentonite Pellets ❑Bentonite(2(rsolids) ❑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. 1 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 WORK]CMPENSATION��LAWS. tort N UM 24 HOUR ADVANCE NOTICE.REQUIRED FOR INSPECTIONS1 SIGNED `�^P� TITLE 1 e/ ( 1s�� DATE - l 1 - - -- PE SC Amount Chec I Received Date Permit/ Invoice# Well ID# Codes Info Remitted Ca By Service Re uest# 365, tfL �SQ 0038 5,01 EHD 43-02-006 MASTER WATER WELL PERMIT 5/7122-002 Is exempt herefrom and the basis for the auegeo exempnon. my vrolanon of 6cuuOu rwc.J Uy uuy dpplloUUL IVI >a FVIL us auVJeem '.rvutt s..a:rivilnertaltunf....I rnrmP than five hlmdred dDllam(S500).).__