SR0071751 - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205- (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED G JOB ADDRESS CITYIZIP 2364 ROLERSON ROAD STOCKTON / 95206 m co M CROSS STREET.__WOLFINGER ROAD APN 162-160-04 _PARCEL SIZE JI AC. LAND USE APPLICATION# Cr OWNER NAME JUDITK_L BALCAO,TRUSTEE OF THE JUDITH SALCAO TURST, LAD DECEMBER 29, 2000 3., PHONE 01 OWNER ADDRESS 6634 CUMBERLAND PLACE __ _ Cm/STATE/ZIP STOCKTON / CA / 95219 01, CONTRACTOR ,L1.,yI IirK-f��i-1r��1J��_..ti�_F httu V y�_� ✓IC- PH/O�N�r_A �L�_�v �a 1 CONTRACTOR ADDRESS 0 Ia �/4�e- V� CITY/STATE/ZIPA y,( �./C 4k r06 T� CDCD SUBCONTRACTOR _—-----____—----------._ PHONE__ -------__ CID x Z till, SUBCONTRACTOR ADDRESS CITY/STA ZIP____ _ C�-72• LICENSE C-57 � C-61 D-09 Other._...,..._„_................................... NUMBER,_. ,...S,rd.,.. _ 4..._.... EXPIRATION DATE_ 7 � 6323492 2152713 1N. Range6E. 28 GEOGRAPHICAL INFORMATION: Coordinates X Y_ Township _ Section_ _ �.rarr INTENDED USE Domestic/Private Irrigation/Agricultural V Industrial Water Quality Monitoring Soil Sampling/Characterization Public Water System__________ ___ _ __ _ _ __________—___ If different from Owner _WaTe7T�yslemWa_me— ---contact Name or PForre FTumber r� TYPE OF WORK %New Well Replacement Well Well Alteration/Modification Other s LL #of[wrings #of borings to Monitoring Wells) _#of wells Soil Boring(s)_ Geotechnical Un Out-Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair 0 01 New Pump Pump Replacement Pump Repair Raise Well Casing WELL CONSTRUCTION i�/J Drilling Method Mud tary /, Air Rotary Auger Cable Tool Push Point Other Proposed Well Depth_. �dft Excavation -- in in diameter Open Bottom Gravel Pack/Gravel Size,_„_,_,_9, in diameter Conduct—Casing____in diameter ! Cond inr C asin Depth In Thickness/Gauge/ASTM Schad �T Steel Plastic *X Stainless Ste% Other____ Well Casing Diameter _ Grout Seal Depth-,&2 Neat Cement(94 lb bag/5-10 gal water) Sand Cement_�b� sack mix17 gal water Bentonite(20%solids) Other Grout Placement Method Pumped* Free Fall Other Retardant/Accelerator(name) PEDESTAL Installed By Driller Pump Contractor X Other Concrete Pedestal Dimensions:Width ft Length it Thick in Christy Box Stove Pipe PUMP Submersible Turbine Other HP Pump Set It Standing Water Level ft i 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 I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATI N LAWS. MINIMUM U AD Nr r REQUIRED FOR I�(j�LSPECTIO -PLE 9 3 / gg " D SIGNED :._.._...._ _ `�w`• L TITLE----_- L ITLE______ 'y jL 11 0?%l r oAki I 1 11— f, r ri I 'red F'�it117oout Tp or inspec' with Division I P G RN M DEPARTMENT U E NLY 1 _ Application Accepted By Date �� Area_._0-1l ..__ EmployeelD#_ � Grout Inspection By Date___��_•••______ SPECIAL Well Permit PAYMENT Pump Inspection By Date ______________ WAIVER Received RECEI�IE-� Sal Boring Inspection By ___ _---._.,_.__._ Date ..._.... __._._._ Constructed Well Depth _ _ ft ^O{f COMMENTS — ��j 1 L 1 _ — --- {` 1 PE Sc Received Check#/ Amount Date Permit/ Invoice# Well ID# SAN EWA”- R T Codes Info B Cash Remitted Service Re uest# H1STNoNM OE.FMFtTMEN �7 � Vi 1,A . 3AVY3 59.0611'751 EHD LI Joe. to NO. 2015-24 2A1