SU0004816 - Laserfiche WebLink

Home Browse Search

WLI EL, / YU1V1Y rEMV111 SAN JO UIN COUNTY ENVIRONMENTAL HEALT' RPARTMENT 304E WEP- AVE 3"'FL-STOCKTON CA 95202 - (209)468-3420 NO EFUNDABLE PERMIITC \aeo' CALL(2y09 953-7697 FOR INSPECTIONS NweEXPIRES 1 YEAR FROM DATE ISSUED r Joe A DRESS �ZS6,5 S! ��r" /^S /`I-/J Q CITY/ZIP 44 �.J CROSS STREET rL4Q APN IZE +- OWNERINAMe 5g1F/� C/�}� �Jr �BeC1�J57-/^7✓ GJ PxoN�+ �y�� /fes' o�sC JIM } OWNER ADDRESS 9DZ� �� CITY/STATE/ZIP CONTRACTOR S — 'PHONE �b CONTRACTOR ADDRESS -94=20ZW&=e—d-r A96 CITY/STATE/ZIP CJe2q 9sa/ ecz ti .}, suecoNTRACTOR ////1oL f-f-fS f>JG��-//f�L7 PHONE! - 5 SUBCONTRACTOR ADDRESS /�% r `— CITY/STATE/ZIP ///Oaol 4/4 LICENSE -57 ❑C-61 13D-09 ❑Other NUMBER Z - 'ZeZ EXPIRATION DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section INTENDED USE mestic/Private ❑Irrigation/Agricultural O Industrial ❑Water Quality Monitoring ❑Soil SamplingJCharacterizalion ❑Public Water System IfdiRerentfrom Owner. Water System Name Contact Nam or Phone Number TYPE OF WORK 1*6ew Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other 5 ❑Monitoring Well(s) number of wells Soil Boring(s) oumberofborinp ❑Geotechnical number of borings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ew Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTIO '0n Drilling Method Aud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other .t]. Proposed Well Depth 2/1z It Excavation17- in diameter ❑Open Bottom vel Pack/Gravel Size y in diameter ❑Conductor Casing in diameter / nductor Casing Depth ft Well CasingDiameter ��,i.�n� Thickness/GaugdASTM S � ❑Steel �lastic ❑Stainless Steel ❑Other r Grout Seal Depth—QY.b[—ft ❑Neat Cement(94 lb hug/5-10 gal wafer) ❑Sand Cement suck mix/7 gal water Cl Bentonite(20%solids) ❑Manulzcturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Grout Placement Method Mumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By ❑Driller )Vump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width III ft Length H Thick____b in ❑Christy Box ❑Stove Pipe PUMP bmersible ❑Turbine ❑Other HP Pump Set "it Standing Water Level J��.ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water ft O Casing to be Perforated from it to ft Sealing Material ❑Neat Cement(94 lb Aug/S-10gal water) ❑Sand Cement sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(2(a/a solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fail ❑Other ❑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 I AM IN COMPLIANCE WITH ALL WORKERS CO ATION LAWS. M 24 HOJUR�ADVANCE NOTICE REQURrE'D FOR!, SPECTIONS SIGNED -r TITLE /Y��- �_ DATE Z 44 of � 1. rn jL 17, it i DEPARTMENT USE ONLY Application Accepted B Date 11- i-�'L Area_� Employee ID# S b to Grout Inspectio By Date ��c: S/bj ❑ SPECIAL Well Permit Pump inspecti Date,, ,17, ❑ WAIVER Ree¢IY¢d Destruction Inspection y Date Constructed Well Depth ✓s s3 PE SC Amount Check#/ Received Permit/ Codec Into Remitted Cash By Date Service Request# Invoice# We111D# b z� 3©` � � l I16 5 003 z i O Z 0 0 a Lfb R00�21�10 � ) (?U Z 5 d r1 EHD43-02-006 MASTER WATER WELL PERMIT 5n/2oo2