SU0010083 - Laserfiche WebLink

Home Browse Search

WELT, PUMP PERMIT SAN JOAQUIN'COL'N'TY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3""FL-STOCKTON CA 95202 - (209)468-3420 t NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS !J o(J •'J ``Q,.c ��1'i .. (t_�, CITY,ZIP? /p�'.1- 'YQY�. .C--'�,.5 1 a�� n CROSS STREET r�-I-✓•{1�.�, S'C7✓�if (}'�� APN �� PARCEL SIZE �.�/I Q• P OWNER NAME / �!/-+�Qnf��h o ( ,`��t-+Y'1 C P_HONE OWNER ADDRESS -? OC//ye (.in f�.`.- /tT' .Q. = C+f r Crry/SrATFJ"LIP S I tj � . - CONTRACTOR y �� PHONE��//�� i CONTRACTOR ADDRESS / 1_7 ACITV/STATFJZIP r SUBCONTRACTOR _ _ PHONE i SUBCONTRACTOR ADDRESS CITYY/S7A"rE/ZIP LICENSE C-57 0 C-61 0 D-09 0 Other NUMBER /I4 '?_ EXPIRATION DATp2-6:'0---'— + GEOGRAPIIICAL INFORMATION: Coordinates X Y_ Township Range__ Section INTENDED USE ❑Domestic/Private 0 Irrigation/Agncultural 0 Industrial 0 Water Quality Monitoring 0 Soil Sampling/Characterization j Public Water System n JO i n N �t'r^^r 1 I1t{P �b>1/�'1_ C Y 1 5 �� 7 y(A`dt�Z�o ]fdifferem from Owner mer stcni �nl -N—oYPohne umumser i I TYPE OF WORK O New Well 0 Replacement Well 0 Well Alteration/Modification 0 Test Hole > Ohher ♦ / . /' 0 Monitoring Well(s) _ mlrberof—tts 0 Soil Boring(s) nwnber of borings IJ Geotechnical numberotbonngs ((�� 0 Well Destruction ❑Out-Of-Service Well 0 Out-Of-Service Well Renewal \} 0 New Pump ❑Pump Replacement 0 Pump Repair 0 Cross-Connection Repair Q ELL CONSTRUCTIQN Drilling Method1ud Rotary ❑Air Rotary ❑Auger`� ❑Cable Tool El Push Point ❑Other Proposed Well Depth,__. _It Excavation �y/ to diameter 0 Open Bottom Gravel Pack/Gravel Size in diameter _`�_.- 0 Con lucto r�mg in diameter / Conductor Casing Depth fl Well Casing Diameter�m Thickness/Gauge/ASTM Sched .2f�o 0 Steel WPlastic 0 Stainless Steel ❑Other Grout Seal 'Depth,_ft 0 Neat Cement(941h hag/3.10ga1 water) Sand Cement/j• suck miv/7 gal water �}7ayrsto¢if�'( lcsykidej� ❑Manufacturer Spec%solids % Name _ ❑Specs on File ❑Specs Submitted Grout Placement Method xpumped ❑Free Fall ❑Other __ ❑Retardant/Accelerator(name) 'IrEDESTAL Installed By 0 Driller n amp Contractor OOther Concrete Pedestal Dimensions: Width ft Length _f) Thick Jin 0 Christy Box ❑Stove Pipe PUMP 'dSubmersible 0 Turbine 0 Other lip Pump Set ti Standing Water Level ft WELL DESTRUCTION 0 Open Bottom 0 Gravel Pack 0 Uncased 0 Other Well Diameter in Total Depth R Depth to Water A ❑Casing to be Perl'orated from -ft to A Sealing Material 0 Neat Cement(94/h bag/5-10 gal water) 0 Sand Cement sack inir/7 gal water 0 Bentonite Pellets 0 Bentonite(20%solids) O Manufacturer Spec%solids % Name 0 Specs on File 0 Specs Submitted Placement Method 0 Pumped 0 Free Fall ❑Other 0 Complete with Mushroom Cap tlbelow grade 0 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. 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 COMPENSATION LAWS. r MINI24 HOUR ADVANCE NOTICE RERUIRED FOR INSPECTIONS SIGNED—j I ' - ` TITLE >`,NI�fL r DATEQ i F.1-' K GG 11 LUL J J. w, -t - - I r J Ol t4 _ r EF 1H - EN\'IFONh"ic,iTA r+ .'/ DEPARTMENT USE N' Application Accep By t ,f/LGtyt� Date_ _:2c.— Area Employee ID# _ Grout Inspection By_ Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Dale _ Constructed Well Depth A COMMENTS PE SC Amount cck# Received Date Permit/ Invoice# Well IDN Codes Info Remitted By Service Reclucst# 24- - ,2o1�3a657 Z� EHD 43-02-006 MASTER WA1 ER WELL PERMIT