COMPLIANCE INFO_2004-2006 - Laserfiche WebLink

Home Browse Search

WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT ARTMENT 304 E W VE 3"D FL - STOCKTON CA 95202 - (209) 468-3420 NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR F MDAATE ISSUED JOB ADDRESS �k/_! J ,�/A/S�-/' ,Q / %�''v CITY/ZZIIPj� 7 lG/ko �7 CROSS STREET ,�� A `r I ' `0e V "d APN �� el)6 s `'7 PARCEL SIZE / � / OWNER NAME r, VV P"� `J 1N ��TV--ft I q=TC.? PHONE Drilling Method ❑ Mud Rotary *ir Rotary )il./luger ❑ Cable Tool ❑ Push Point ❑ Other OWNER ADDRESS 00 �,/��^('�� ��C''(�� CITY/STATE/ZIP ��J�-� Well Casing Diameter '2- in in Thickness/Gauge/ASTM Sched CONTRACTOR MINI/t_1) p. ��y1/t k-. S'QF—?-P 1 S ft5slo ik-Tl s PHONE �N CONTRACTOR ADDRESS VIGO ft"- 1 m/s'l—pc / C1—' CITY/STATE/ZIP E)jkM6N�z) SUBCONTRACTOR 1 � �� �1DPV CI, V �T�',.�VtC� �VL�� PHONE �Mp �C'��+�''��Q� /� ,�% SUBCONTRACTOR ADDRESS 1V F ftZ� :J T `�% 1V V CIIT'Y/STATE/ZIP � ��yL.(��'j�1 (-�� 6W It* I C -A--• `',` LICENSE �C-57 ❑ C-61 ❑ D-09 ❑ Other NUMBER iJ� EXPIRATION DATE Ci—W-0+ 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 0 -Other Ceirrz t=X NK.rz— tiUIV gnumber of borings ,$[Monitoring Well(s) 17.1-61 number of wells ❑Soil Boring(s) number of borings 11 Geotechnical ❑ Well Destruction ❑ Out -Of -Service Well ❑ Out -Of -Service Well Renewal rl N— P—n ❑ Pmmn R—Innement ❑ Pumn Renair ❑ Cmz.--Cnnnectinn Renair WELL CONSTRUCTION S€� Drilling Method ❑ Mud Rotary *ir Rotary )il./luger ❑ Cable Tool ❑ Push Point ❑ Other Proposed Well Depth 2C— ft Excavation 16'T7- in diameter ❑ Open Bottom ❑ Gravel Pack / Gravel Size in diameter rrrCasing Depth ft fit �- ❑ Conductor Casing in diameter /" Conductor Well Casing Diameter '2- in in Thickness/Gauge/ASTM Sched ❑ Steel Plastic ❑ Stainless Steel ❑ Other Grout Seal Depth tt ❑ Neat Cement (94 lb bag / 5-10 gal water) ❑ Sand Cement suck mix / 7 gal water ❑ Bentonite (20% solids) ❑ Manufacturer Spec % solids % Name ❑ Specs on File Xspecs Submitted Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant / Accelerator (name) PEDESTAL Installed Byr ❑ Driller ❑ Pump Contractor R � ❑ Other IV -OR p ')6E--5 ❑ Concrete Dimensions: Width Length Thick in Christy Box ❑ Stove Pipe PUMP ❑ Submersible ❑ Turbine ❑ Other HP Pump Set It Standing Water Level ft WELL DESTRUCTION ❑ Open Bottom ❑ Gravel Pack ❑ Uncased ❑ Other Well Diameter in Total Depth It Depth to Water It ❑ Casing to be Perforated from ft to tt Sealing Material ❑ Neat Cement (94 lb 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 ❑ Pumped ❑ Free Fall ❑ Other ❑ Complete with Mushroom Cap ft below grade ❑ Complete to Existing Surface Pad 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. 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. ANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 95}3-76s9/7 /� 74 TITLE �/�-rl�j-S DATE /� (svC/T Application Accepted By Grout Inspection By Date Pump Inspection By Date Area Employee ID#3143 ❑ SPECIAL Well Permit ❑ WAIVER Received Destruction In ection By Date Constructed Well Depth ft COMMENTS . j — U -':t4 C D PE SC Receivedhec Codes Info B Amount Cash Remitted Date Permit/ Service s Invoice # Well ID# �3 6 7'7 'PYA EHD43-02-006 MAN ItK WAItK WtLLrtKM11 12/6/2002 4