COMPLIANCE INFO_1995-2006 - Laserfiche WebLink

Home Browse Search

WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH D MENT 304 E WEBER FL - STOCKTON CA 95202 - (209) 468-3420 NON-REFUNDABLE PERMIT ALL ND (209) 953-7697 FOR INSPECTIONS IRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 276S7 cauvm� c (if,�,/ 9_ CITY/ZIP 66-70 WIN CROSS STREET � 1�� /� APN ! ` 9 PARCEL SIZE t� OWNER NAME 0561 PP--I-r-6 Le-t4��Pal,sa S G�/4S �'4Q�� 1�(y J/P�,HON+E� A/O� i�� /3�r��/� OWNERADDRESS 30/© .4 0U �1 Ll/ � ` �� GL! J CITY/STATE/ZIP Jar. t h " . rA WV) CONTRACTOR v FV W1ryff mc- w 1/ PHONE 7` 7— /2!7 CONTRACTOR ADDRESS19 T^ ` IT-& L �l ALO �{�l CITY/STATE/ZIP A////1 SUBCONTRACTOR cGA�M`IIL 1�� ALL. PHONE 2D ` Z/�2�'A' SUBCONTRACTOR ADDRESS a_0 2y oe cha��►l`�� CITY/STATE/ZIP r roatlw (w- LICENSE L� Q�710 LICENSE 0C-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 Owner: Water System Name Contact Name or Phone Number TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Test Hole ❑ Other ❑ Monitoring Well(s) number of wells ❑ Soil Boring(s) number of borings ❑ Geotechnical number of borings ❑ Well Destruction ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal n Naw P' m li P' m Ranlararnant rl P'- RPnair rl C—e-C-n-tinn Pamir WELL CONSTRUCTION SC Info 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 ❑ Conductor in diameter / Conductor Casing Depth ft tC-asing Well Casing Diameter � +L in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth i 0 ft ❑ Neat Cement (94 lb bug / 5-10 gal water) ❑ Sand Cement suck mix / 7 gal water ❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids % Name Q9 V_ e ftjte. ❑ Specs on File ❑ Specs Submitted Grout Placement Method ❑ Pumped 01'ree Fall ❑ Other ❑ Retardant / Accelerator (name) PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other ❑ Concrete Pedestal Dimensions: Width ft 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 ft ❑ Casing to be Perforated from ft to ft Sealing Material ❑ Neat Cement (94 lb bug / 5-10 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 I 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. 1 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. M 1 U VA E NOTICE REQ JRED FOR INSPECT O S —PLEASE CALL (209) 953-769 TITLE SIGNED A ^l A i e/'� � t ��+ DATE d / DEPA�/�M )j USE N/V Application Accepted B�^' l Q°� � afe�! Area Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By f Date Constructed Well Depth It COMMENTS (Al T M a v v a rn PE Codes SC Info Received Check#Amount Permit/ By Cash Remitted Date Service Request # Invoice # Well ID# -51-Wo3 SRQQ33S_()�, EHD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002 C) 4 -