SU0009951 - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMIT I—QU rA F SAN JdAAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE 3"t Ft:a STOCKTON CA 95202 -(209)463.3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED �� 'L3 JOB ADDRESS CITY/ZtP ee CROSS STREET ♦ , � w I�)•^� APN—k PARCEL SIZE S-- 1°a OWNER NAME ILII.\\�`fDV1�CJ1 PRONyE,.,,�&,V„-L'QIn-�`-r1 tU.1 OWNERADDRESS �J,,Jq,�1 IVL). /'LZy t�QV lI]Yl/, CITY/STATE/ZIP AWtk IkPr- I`�`-7 tONTRACTOR MQltT^-�11 C,PHONE �g�,ft,e-ota-4 -SF44 CONTRACTOR ADDRESS W(a t,�YL7�7C.1t II�Y�_ 1L� aQ -7 r 1 CITV/STATE/ZIP aC lAllQr +P�, j �a CA-`' ('] , SUBCONTRACTOR� 22,� D 1�J►/(�Y_��1) - PHONE 0- - 14,99 SUBCONTRACTOR ADDRESS�Sl�� 1.11T\Yf� �lm � Crt`•YISTAAT1trl'Z�IP kA�dw LICENSE IY C 57 ❑C-61 ❑D-09 ❑Other NUMBER L�J1lJ EXPIRATION DATE -T GEOGRAPH[CALINFORMATtON. Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring Soil Sampling/Characterization ❑Public Water Sy tem 1f aiffcrent from Ownei: .ter ystem ams Cmt.,Nams or Ph—N..b. TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteradon/Modincation ❑Test Hole ❑Other ❑Monitoring Well(s)__ nomlb—I'wells M<oil Borings)_.0 numberorborinp 13 Geotechnical cambezofbotmgs ❑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 C3 Air Rotary 6YAuger ❑Cablc Tool 17 Push Pain: ❑Other Proposed Well Depth_k5 Il Excavation_ X in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth —R Well Casing Diameter_in Thickness/Gauge/ASTM Schell ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth I1 R ❑Neat Cemau(94 1h hrrg/5-10 gal wu(er) ❑Sard Cement ,ruck mix 17 gal water ❑Bentonite(201/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__11 Length R Thick in ❑Christy But ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other_ HP__ Pump Set ft Standing Water Level 11 WELL DESTRUCI•ION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other 11 Well Diameter in Total Depth It Depth to Water B ❑Casing to be Pert'orated from tl to It Sealing Material ❑Neal Cement(941h hag y3-/0 gul rwl/er) ❑Sand Cement suck mix/7 gal water ❑Bentonite Pellets ro ❑Bentonile(2D%solids) Q Manufacturer Spec%solids % Name l` ❑Specs oo File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall dother _11b 1�c�ftil( �i1 C l,l 1��Q5 1 O Complete with Mushroom Cap tl below grade ❑Complete to Existing Surface Pad— J 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 11I 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 I AM IN COMPLIANCE WITH ALL n WORKERS COMPENSATION LAWS. ^ MINIMUM 24 HOUR ADVANCE NOTICEREQUIREDFOR INSPECTIONS SIGNED TITLE LJyiltVrylnja3� rM DATE_ 11� pa v5 1.0 FPO LY � TM i DEPARTMENT USEQNLY Application Accepted By Date Area�G Employee ID# (% Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspcc0 By Date Constructed Well Depth ft COMMENTS O ;�i'!rt re s Rhs o 1 �zf[r sr✓{d /�� 1/•'eLrU�i_c Gl/1 CGt ZAitu I z PE I SC Amount Received Date ermiU Invoice# well ID# Codes Info Remllted ash B Service Request# I anO S�oo3ri 0 W EHD 43-02-006 MASTER WATER WELL PERMIT