SU0004307 - Laserfiche WebLink

Home Browse Search

W L{L / Y U lV Vll l SAN JOAQUIN COUNTY ENVIRONMENTAL.HEA}0iDEPARTMENT _ 0 304 E WE Ave 3"°FL-STOCKTON CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT CALL 20 - FOR NSPECTIONSe EXPIRES 1 YEAR FROM DATE ISSUED JOB ADbRES5 F_�f II I / CITY/ZIP 1 r s g y} �,CC� G C CROSS STREET f APN Z 7 --2-2-00S" PARCEL SIZE to E OWNER NAME Ce+ v ' VW PHONE - - OWNERADDRESS - CITY/STATE/ZIP CONTRACTOR PHONE �r CONTRACTOR ADDRESS 'CITY/STATEI'LIP rn SUBCONTRACTOR �/J L—� PFIONE •g1 er7��lo�✓�•�'' SUBCONTRACTOR ADDRESS `L=a /�_ I 7 /�' '"� CITY/STATE/ZIP S T_KN ci 7 17— UZ3 LICENSE -$7 0 C-61 ❑D-09 ❑Other NUMBER , G� EXPIRATION DATE C:) >__ GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private 13 Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System Irdifferent from Owner Water System Name Contact Name or Phone Number TYPE OF WORK ❑New Well 0 Replacement Well ❑Well Alteration/Mod'ficati u ❑Test Hole ❑Other Q nomber orweiis number or borings number or borings ❑Monitoring Well(s) Soil Borings) ❑Geotechnical ❑Well Destruction. ❑Out-Of-Service Well ❑,Out-Of-Service Well Renewal ❑New Pum '❑Pum Replacement ❑Pump Repair ❑Cross-Connection Repair -VAYbFi.CONSTRUCTtON .. Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool ❑'Push Point ❑Other' Proposed 41JR6 Depth tt Excavation' 4—(o in diameter ❑'Open Bottom ❑Gravel Pack 1 Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth Il Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Sea] Depth ft ❑Neat Cement(941h hug 15-10 gal wafer) ❑Sand Cement sack mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted 'I Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL. Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width - ft Length R Thick in ❑Christy Box ❑Stove Pipe I PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set It Standing Water Level tt I MMODESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth It Depth to Water it ❑Casing to be Perlbrated from ti to ft Sealing Material ❑Neat Cement(941b hug 1 S-10gu1 water) ❑Sand Cement _suck mix/7 gal water Bentonite Pellets 1 0 0 0 r� ❑Bentonite(20%solids) � ❑Manufacturer Spec /a solids /a Name. ❑Specs on File ❑Specs SubQmitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap tt below grade ❑Complete to Existing Surface Pad 1 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 THF,,VLIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMff NSATION LA NI U 4 HOUR ADVANCE NOTICE REQUIRED'FOR INSPECTIONS SIGNED TITLE Dn-I'E I I � j Z) =f I Q 0 104:11* SI nJ` Y M � sax[: op � I` r BRADY ROAD � I w +DEPARTMENT USE ONLY �qY Application Accepted By �04 ckulu Date -7--"— 0 Z- N Area Employee I D# 53U Grout Inspection By ry� _ Date ❑ SPECIAL.Well Permit Pump Inspection By Date _ ❑ WAIVER Received Destruction Inspection 1. Datcp_o Constructed Well Depth ft COMMCNT5 i PE SC Amount•. reek# Received Date Permit/ Invoice# Well FD# Codes Into Remitted By Service Request# EH 43-02-006 MASTER WATER WELL PERMIT 5n/2002