Laserfiche WebLink
J1 WELL/PUMP PERMIT <br /> SAN JOAQOIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 314E WEBER AVE 3NA FL-STOCKTON CA 95202 -(209)468.3420 <br /> . <br /> NON-REFUNDABL <br /> �frE PERMIT 1'�{ (�CA/�LL 209 955-7697 FOR INSPECTIONS EXPP'IIR�tE�S I YEAR FROM DATE ISSUED <br /> t CA <br /> JOBADDRESB IyO0 S 1-�e�,de JOfr CITYI7,IPf 111{� �.��-I <br /> �' �..., <br /> CROSS STREET t)r7 APN. lN_ _J' I-10 — O 2Z PARCELSI7E �G` Is <br /> OWNER NAME r r R PHONE rNv PG+ <br /> OWNER ADDRESS LV Div- V Crry/STA'tMtr 141 ` <br /> CONTRACTOR f�A PHONE <br /> COATRACTOR ADDRESS_�r/ t44" _ GCJrGr ./YL - - CITYISfATE2[P <br /> SURCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CrtYISTATVZIP <br /> LICENSE XC-57 0 C-61 OD-09 OOther NUMBERXeaaj6� -EXPIRATIONDATE .� <br /> Pte+ <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section <br /> INTENDED USE O Domestir/Private 0 Irrigetion/Agricultural D Industrial 17 Water Quality Monitoring O Soil Sampling/Characterization p� <br /> 13 Public Weter System <br /> Ifdiffmnt noml7amer: Wulff Syllem Now a —woe u _ <br /> r <br /> TYPE OF WORK O New Well ❑Replacement Well r D Well Alteration/Modification O Test Hole O Other <br /> ❑Monitoring Well(s) numlwr ofwells O Soil Baring(,) -1 11;06- flGeeteehnical namberolbmtap - <br /> D Well Destruction Cf Out-O6Service Well ❑Out-0f--Service Well Renewal <br /> CI New Pump O Pump Replacement 17 Pump Repair D Cross-Connection Repair <br /> i <br /> WELL CONSTRUCTION <br /> Drilling Method' 0 Mud Rotary O Air Rotary D Auger D Cable Tool O Push Point O Other <br /> Q <br /> Proposed Well Depth ft Excavation in diameter Cl Open Bottom D Gravel Pack/Gravel Size—in diameter <br /> O Conductor Casing in diameter f Conductor Casing Depth R <br /> Well Casing Diameter_in ThickncsslGauge/ASTM Schad D Steel D Plastic D Stainless Sted D Other <br /> Grout Seal Depth ft 17 Neat Cement(941h hag/3-10b-ul water) 13 Sand Cement rock mix/7 gal water <br /> DBentonite(20%solids) DManufacturer Spec°Fesolids SS Name OSpecsonFile OSpasSubmined <br /> Grout Placement Method O Pumped O Free Fall D Other D Retardant I Accelerator(name) <br /> PEDMAL Installed BY 17 Driller O Pump Contractor D Other <br /> 17 Concrete Pedestal Dimensions: Width_R Length 1t Thick in 0Christy Box 13StovePipe <br /> t PU DSubmersible 13 Turbine OOther HP Pump Set B Standing Water Level ft <br /> I <br /> WELL DESTROCTION D Open Bottom 0 Gravel Pack 17 Uncased D Other <br /> Well Diameter in Total Depth ft Depth to Water H DCasing to be Perforated from fl to ft <br /> Sealing Material ❑Neat Cement 04 fh img/3-10guf woferl q Sand Cement sm*mir 17 gal water D Bentonite Pellets <br /> D Bentonite(20%solids) D Manufacturer Spa%solids_% Name O Specs Dn File O Specs Submitted <br /> Placement Metbod D Pumped ❑Free Fall OOther <br /> D Complete with Mushroom Cep B below grade ❑Complete to Existing SuKxe Pad <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. i ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> 1, MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TIRE ! - <br /> I <br /> i <br /> x <br /> w <br /> fnK <br /> =w <br /> �x <br /> z <br /> z <br /> --f Applicalian Accepted By AICsmplDpus IDN !� <br /> Grout Inspection By /r[ Date ❑ SPECIAL Well Permit <br /> Pump Inspection By C� Date ❑ WAIVER Received ! <br /> I <br /> Destruction Inspection By Deu :d Constructed Well Depth - it I <br /> COMMENTS Loa D <br /> l PE- SC Amount Mee eeelved Info Remitted Date Permit! <br /> CadIavdeeN WeII1DB <br /> Cod" ash B SorvkeR Dest B <br /> b - ja3o 6 OR o z t <br /> E 2-006 <br /> sn12002 MASTER WATER WELL PERMIT <br /> naas <br /> I � <br />