SR0030798 - Laserfiche WebLink

Home Browse Search

WELL 1 PUMP PERMIT /J, ° r - G01 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 310 FL-S'rocm-oN CA 95202 - (209)469-3420 NON-REFUNDABLE PERMIT CALL 209 953-7$97 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUFD fto JOoADDRES5 �5yo vSd �— � � rt CITYIZIP ► +' YQw«L--- ` )--;3 3 r I n CROSS STREET s 1 APN 2--L%A ~V y r PARCEL SIZE OWNER NAMEPH/O�NE F-0. � OWNER ADDRESS 1 •O• vo ox CITYISI'ATEIZIP • v � �^"1 �� CONTRACTOR PHONE CONTRACTOR ADDRESS CITY/SfATErLIP SUBCONTRACTOR_ PHONE 91" S11BCONTRACtORADDRF4,S Y �1r-kk� CITYISTATEIZIP 5l � ■ CAl id'L d52 4'+��[-_+, LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER Z45—z EXPIRATiON DATE �Z GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring °�� ❑Public Water System If different from Owner: Waier Sysienn Norm Contact Norm or?hone Number TYPE OF WORK ❑New Well ❑R.'.placement Well ❑Well Alteration/Modification ❑Test Hole ❑Oilier ❑Monitoring Well(s) number of wells number of borings XGrolechnical number of borings _ Soil Boring(s) ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION . Drilling Method ❑Mud Rotary ❑Air Rotary 14 Auger ❑Cable Tool ❑Push Point ❑Other Proposed W*W Depth ZS ft Excavation—Itc, in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter M Conductor Casing in diameter 1 Conductor Casing Depth Il Well Casing Diameter in ThickneWGauge/ASTM Sched ❑Steel ❑Pis.stic ❑Stainless Steel ❑Other Grout Seal Depth fl ❑Neat Cement(94 lb hug/5-10 gal%weer) ❑Sand Cement sack mix/7 gal water t) ❑Bentonite(2(0/6 solids) ❑Manufacture;Spec%solids % Name _ ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDEYrAL I ristallo By, 0 Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width _ fl Length fl Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level H Webs DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth fl Depth to Water fl ❑Casing to be Perforated from fl to fl Sealing Material ❑Neat Cement(94 Ih hug 15-10 gal water) ❑Sond Cement suck nail 17 gal water )(Bentonite Pellets Cek I 1\l ❑Bentonite(20%solids) ❑Manufacturer Spec%solids---■10 Name ❑Specs on File ❑Specs Submiu Placement Method 10 Pumped 11 Free Fal l 13 Other fd ❑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 SANSk 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. MADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE 1 1��. DATE -- --- - - -- - ----- - r- li TTrr__'' ■ QfJ i i s ■ i ■ ■ I •' ■ e ■ ■ . • R it ■ Ir I i.i_ r.;IN_- ' ■ \ sJ" { !rpt ! � • �_'y_irir_ij -- ��• - II - I I- -N' ■ ■ . - a ■ ■ r — DEPARTMENT USE ONLY Q Application Accepted By Date �UZ Area oK Employee ID# f 7� Grout Inspection By ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth fl COMMENTS PE SC Amount k,_S!ecW Received Dale Permit! Jnvoiceq Well 11D# Codes Info Remitted ash BYwry OF EHD43-02-006 MASTER WATER WELL,PERMIT 5/7/2002