FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

CLL / PUMP PERMIT • r SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOH ADDRESS- / ` CITY/ZIP. `7—kAey 0 CROSS STREET 344n/L1 /ZbdA APN Z49-0.3Q+ OS PARCEL SIZE_QSIJ4e LAND USE APPLICATION# � m OWNERNAME --MmAeK (folm maAI1-nf-; PHONE 2o9-2f34-/5l0/� •`•' OWNERADDRESS /312D DM&Ly &LID- 51117---4 CITY/$TATE/ZIP I & yiCA 95�376 CONTRACTOR C- nAJ116r RAA2-rul A0z",IA-5 - I/A4 !-PHONE 2aq:2.34-.151A CONTRACTOR ADDRESS I?$ FzJ►A/e Wk'S7- /'T (JCI '5'¢.17 S CITY/STATE/ZIP S�TL76-KTUIU� C-./T g52"-�ig SUBCONTRACTOR :! tP T2,LJ19A PHONE 219q+yAi5-R1 Y/Z SUBCONTRACTOR ADDRESS d CITY/STATE/ZIP S'7CILlL� (-A !9520!j / LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DATE () Q V GEOGRAPHICAL INFORMATION: Coordinates X Y Township -/ L Range-JL-f, Section-_.3.1 INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial X*ater Quality Monitoring ❑Soil Sampling/Characterization (� ❑Public Water System v If diffemnt from Ownm Conuict Name or Phone Number TYPE OF WORK P(New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other 9Monitoring Well(s)�#of wells ❑Soil Boring(s) #ofbodngs ❑Geotechnical #ofbadngs /❑`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 Auger :. ❑Cable Tool ❑Push Point ❑Other _ Proposed Well Depth /11'h 25 ft Excavation +in diameter `. ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth fl O Well Casing Diameter I" in Thickness/Gauge/ASTM Sched '40 ❑Steel Plastic ❑Stainless Steel 13 Other Grout Seal Depth 0-:/4 6-11/ft {Neat Cement(94 Ib bag/S-10 gat water) ❑Sand Cement ,sack mix/7 gal water Tj- 0 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& It Length-f .o It Thick y j!n in ❑Christy Box Mstove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Se[ ft Standing Water Level ft WELL DESTRUCTION 0 Open Bottom ❑Gravel Pack ❑Unused ❑Other Well Diameter in Total Depth ft Depth to Water ft Cl Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(94 Ib bag/5-10 gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec e/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 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 1 AM IN COAPLIANCE WITH ALL WORKERS COMPENSATION LAWS. �MUM�2+4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED � +^� (.-CMVj1dt��OM /6e TTi'LE �'T/1 F'F ( 7�L�w1 S'T DATE p i� �-1 ;09 C NT .DEPARTMENT USE PNLX Application Accepted By .i Date 4 Y Area Employee ID# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection�B(y q,. Date yConstructed Well Depth, R COMM TS 5�/h�(�7 �J� �r+Y (LtAd-{ •e W� l GAVE' VA1114,I 9*11NA7' PLIW DiA gut d PE SC Receivedec Amount Permit/ - Codes Info B ash Remitted ff to Service Re nest# Invoice# W¢II ID# / EHD C]-03-0ofi 03 MASTER WATER WELL PERMIT EHD3-