SU0008578 - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMIT SAM JOAV(JIN COUNt'Y ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE 3"FL-SToci ToN CA 95202 -(2D9)46g-3420 .NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATbISSUED JOnADDpESs CITY/Zlp rkt-ea _ A n � d Caos55raELT D�fbth. �-{,Wy _ APN -1 �-0 PARCEL$IZE 1-19 OWNER NAME f. 1 Cpm.1"I -Ak .�. .- PHONE�( —Li9 OWNER ADDRESS _�rA,.tJ I7IL}'� Sl,a. l-L CfTY/SrATEIZIP:J—a C '7,4 cONTRACTOn l _�cnej�t�enlr 8a. L l�t►Ln 1 t>4 r T�nr PHONE —O CoxtRAcrORADDRess-_l�g i:fe .k (wJCA4 Grl_Jtl Su.i�=CITY15rATFJZIP6ad. ".4+ C qSZOb co O SuseoNTRAcron S -•' PHONE_VO4 SUBCONTRACTOR ADDRESS 'V3,6 5 L1Wr PH, J CITVMA�TFFJttZIP_. S 1i7CJ , r LICENSE C-57 0 C-61 0 D-09 0Other NUMBER f G�-o� EXPIRATION DATE 1q./30/2C3 q i GEOGRAPHICALINFORMATIONr Coordinates X Y Township_ Range Seetioe INTENDED USE D DomeaticlPrivate ❑lrrigatiodAgricukural ❑Industrial 0 Water Quality Monitoring ❑Soil Sampling"aracteriution ❑Public Water System C� . If .ditTsrent nem Owner: arer Symem Ns..c. Damn arae'Pu f TYPE OF WORar ❑New Well ❑Replacement Well O Well Aluniion/Modification 0 Test Hale 0 Other - ❑Monitoring Well . —b-.r lh ❑Soil 8origs) -n4cr oTbmta rrumaaefEodnps d Geotechnical ell Destruction ron,L Pl qj) D Out-O&Serviee Well 0 Osi-Or-Sevce Well RenewalKNumRlece0 Pump Repair OCrss- onnection RM Pum it WELL CONSTRUCTION Drlllin=Method 0 Mud Rotary ❑Air Rotary ❑Auger d Cable Tool 13 Push Point 0 Other Proposed Well Depthft Excavation in diameter ❑Open Bottom ❑Gravel Pack r Gravel Size in diameter 0 Conductor Casing in diameter I Conductor Casing Depth R Well Casing Diameter_in ThicknesslGougrJASTM Scheel ❑Steel ❑Plastic ❑Stainless Seel ❑Other Grout Seal Depth tl ❑Neat Cement 041h hag/S-JOgal water) ❑Sand Ccment suck mix I7gal water ❑Bentonite(20%sotids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Grant Placement Method L3 Pumped ❑Free Fell 0 Other ❑Retardant/Accelerator(nerve) - PEDESTAL lnslalkd By ❑Driller 0 Pump Contractor 0 Other 0 Concrete Pedestal Dlmentlonar Width R Len th g it Thick in 0 Christy Boa 0 Stove Pipe i PUMP Cl Submersible 13 TuFbine ❑Other HP Pump Set ft Standing Water Level h WELL DE3t'RVCTEOn ❑ Bottom ❑Gravel Pack 130 Untried j Other Well Diameter�in Total Depth 19 R Depth to Water:5F-'A It ❑Casing to be Perforated rrom__• L ft to W fl Sealing Material Neat Cement(941h lxug/3.10gal warer) ❑Sand Cement roc*m[x 17 gal water ❑.Bentonite Pellets 0 Bentonite(201/.solids) 0 Manufacturer Spec%solids % Name 0 Space on File 0 Specs Submi{ted Placement Method [Pumped O Fret Fell 0 Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT I 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 THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MOINIUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS ! slctren f!](__�� In r TITLE_S�6 4t Gto�S gwTE n1 � yff Lima i i Application Accepted By Date '.t� , Area�` F,mployee I DN 456 _Grout[mpeclion By _._pale _. _ (7. SPECIAL Well.Permlt_ E Pump Inspation By71 _Date El'd Received Destruction IwVccaion By Date 6 L/d Constructed Well Depth n COMMENTS_GJfor, 17 PESC Amount Ch 1 Received Codes uro Remitted g Date Servleeere uesta InvaleeN Well ION ! 3-3 J6I s MINE EHD 43-02-006 5n/2002 - MASTER WATER WELL PERMIT