SU0006479 - Laserfiche WebLink

Home Browse Search

VV 12j111L1 / r U lvir rjr,Iuvil 1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH' eARTMENT 304 E WEBEP "VE 3"FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL .209 953-7697 FOR INSPECTIONS ..XPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS I`~ ✓ ' l / S ' �Wrl CITY/ZIP �` > CROSS STREET APN zo --,d PARCEL SIZE OWNER NAME � PHONE 1 > K��` q " (0 `�/�s' +�'"7— OWNERADDRESS CITYISTATE/ZIP e CONTRACTOR � 7P,liO�NENE CONTRACTORADDRESS 6f975 X! / ,9a-65)X•'?G CITYISTATE/ZIPT�/7�Y SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE ❑C-$7 ❑C-61 ❑D-09 Asther ald Al2.71- NUMBER 37 EXPIRATION DATE N GEOGRAPHICAL[NFORM1IATION: Coordinates X Y Township Range Seelion r� INTENDED USE mestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System Ifdifferent from Owner: Water System Name Contact Norne or Phone Number TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) number ofwelIs 13 Soil Boring(s) number of borings E3 Geotechnical number or borings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump Inm-p Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method 13 Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth it Excavation in diameter ❑Open Bottom ❑Gravel Pack i Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ti Well Casing Diameter in ThickneWGauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94lh bag/S-l0 gal water) ❑Sand Cement sack onis/7 gal water ❑Bentonite(2(rsolids) ❑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 it Length it Thick in a Christy Box ❑Stove Pipe PUM1tP ' submersible ❑Turbine O Other HPPump Set It Standing Water Level ft WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth it Depth to Water 1t ❑Casing to be Perforated from ti to it Sealing Material ❑Neat Cement(94 Th hug/S-10gal water) ❑Sand Cement sack anis 17 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap it below grade ❑Complete to Existing Surface Pad I 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. 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 WORKERS OMP S WS. MINIMUM 24 HOUR ADVANCE NOTI�REr.AIRED FOR INSPECTIONS 0 SIGNED TITLE DA rt: 5 N .1,VrTT y Application Accepted By Date Area Employee 1D# Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date�7-,�/�O ❑ WAIVER Received Destruction Inspection By Dale Constructed Well Depth 171 COMMENTS PE SC Amount Check# Received Date Permit/ Invoice# Well ID# Codes Info Remitted ash By Scrvk ucst# 05b `1 f3 a 'Woaq77 EHD 43-02-006 MASTER WATER WELL PERMT 5/7/2002