SU0006578 - Laserfiche WebLink

Home Browse Search

11 WELL / PUMP PERMIT I "t- �' SANT- , 'IN COUNTY ENVIRONMENTAL HEALTH 4RTMENT 304E WEBr- /�E�3"FL-STOCKTON CA 95202 - (209)468-3420 NON REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS ' L PIKES I YEAR FROM DATE ISSUED f— �I'J r� •(��_�.�1� .�,. LA inJOB ADDRESS 1Cyyfry CITY/ZIP Mi � .5LT —G— m Nil= esm ,\ •� ,.,�� Q CROSS STREET Z. 1 �a ApN d t //31�L.Gi/� �/PA�R/CEEL SIZE zl CA / OWNERNAME J�sV ;Jr.JTiQSJ)I� GO. <Jt \L� A444 �_ PHONE f46•J�Dt —3o90 OWNER ADDRESS CT OZ G. �.,7r sC�o ,� `' �Q'V CITY/STATE/ZIP pF /[J �f��tl�S CONTRACTOR j( �,K{A 1ok- tl�yteQQ l�� Ojc /� PHONE (4J-744'—t 1440 CONTRACTOR ADDRESS 0. IZO CITV/STATE/ZIP `LA12 —S,s jV e- SUBCONTRACTOR PHON1EQ /•e 4 �• SUBCONTRACTOR ADDRESS N P•f CITY/STATTF/ZIP JK] LICENSE P(C-57 ❑C-61 13D-09' ❑Other NUMBER 5154946 EXPIRATION DATE ` GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section C INTENDED USE ❑Domestic/Private O Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water SystemZ Ifdiffemm from Owner: Water System Name .mbar Narx.r Ph..N.mb.1 TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other Monitoring Well(s) momberofwelis 11Soil Boring(s) mmnberofborings ❑Geotechnical numberofborings !'p ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pum ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other 6'- Proposed Well Depth�� r ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth It Well Casing Diameter _ in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic El Stainless Steel ❑Other Grout Seal [h ft yT Neat Cement(94 fb hug/5-10 gnf wulrr) 1Q'$and Cement .cock rnix/7 gal water +,'t^ Bentonite(20a/solids) 6 Manufacturer Spec%s s_% Name ,` ❑Specs on File ❑Specs Submitted Grout Placement all ad ❑Pumped ❑Free Fall ❑Other tjftia2L ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensionr Width_ ft Length_ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set Il Standing Water Level It WELL DESTRUCTION 0 Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water Fl ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(941h hag/5-10go1 water) ❑Sand Cement sock mix 17 gal Water ❑Bentonite Pellets ❑Bentonite(20"/solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other O Complete with Mushroom Cap ft 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. I 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. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS rj SIGNED TITLE Opeaw tNS R)RCKIW DATE s0 D 4 1�t p1.. D RTMENT U0 qNLYZ Application Accepted B Date Area Employee ID# Grout Inspecti B Date _ /"/air, ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Reeeiv¢d �I�IU11 Destruction Inspection By Date.t Constructed Well Depth It COMMENTS PE SC Amount Check#/ Received Date Permit/ Invoice# Well ID# Codes Info Remitted Cash By Service Re uest# SO ss-rAsot 133 66 3/I C10 7 EHD 43-02-006 " - / a MASTER WATER WELL PERMIT sn/2602