SR0036821 - Laserfiche WebLink

Home Browse Search

WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"°FL-STOCKTON CA 95202 - (209)46$-3420 NON-REFUNDABLE PERMIT CALL,(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED 46'1.5�Lathrb Rd CITYIZIP Lathrop C a �� JOB ADDRESS � Y p yr v CROSS STREET APN ! �r-7- Zo- 11 PARCEL SIZE J M $ 3ts.t : 4&f S r 3 1= L aJGr v.7p) OWNER NAME Sod'th San aauin 'Trri c*a inn nj s;1-r nf- - _ PHONE OWNERADDRESS 2450 W. Yosemite CITY/STATE/ZIP Manteca,rh 9.5337 CONTRACTOR Puryiance nrillers, Tr ,:'. PHONE 2()9-AR7--'AR54 CONTRACTOR ADDRESS P• 0• Box 64 CITYISTATEIZIP Li 11dpn■ Ca 95236 SUBCONTRACTOR PHONE. SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ,O�C-57 ❑C-61 ❑D-09 ❑Other NUMBER 3 7 7(7 1 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: ager ystem ame Contact Name or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other number of wells number of barings number of borings ❑Monitoring Well(s) ❑Soil Boring(s) 11 Geotechnical i Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pimip ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair m WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point El Other I Proposed Well Depth ft Excavation —bL- in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter j ❑Conductor Casing in diameter ! Conductor Casing Depth ft Well Casing Diameter in ThicknesslGauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other j Grout Seal Depth ft ❑Neat Cement(94!b hag/5-10 gal water) ©Sand Cement suck mix 17 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 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 unknown Well Diameter_8in Total Depth 3 1 ft Depth to Water ft ❑Casing to be Perforated from ft to ft Sealing Material r Neat Cement(94 th bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method 'El Pumped ❑Free Fall ❑Other f3jExisting to Ex Complete Completc with Mushroom Cap tt below grade ❑Com p g 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 LA) S. 1 UM 2 , R VANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 SIGNED r' TITLE Corporate Secretary DATE 2/2/04 E ti t 13 A U TA E � A DEPARTMENT USENLY Application Accepted By ({,%(1 .^-_ Date �- 3 Area /(o Employee 1D# j S� Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date ft Constructed Well Depth COMMENTS na 0-r e—.eZ/w 4-F Cip`}&2 v-t/ art - Y` PE SC Received Check#! 1 Amount Date Permit/ Invoice# Well 1D# Codes Info B Remitted Service Request# 3.-7 1(a 3q S3�] EMD 43-02-006 MASTER WATER WELL PERMIT 12/6/2002