SU0003929 - Laserfiche WebLink

Home Browse Search

.30P 1� 1(tiv WELL / PUMP PERMIT '� Snip avnr��rn COUNTY ENVIRONMENTAL HEALTH A�TMENT 304 E WEBER-1 t 3"o FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM MA*&IS'.N'UED to H JOB ADDRESS c��r O CITY/ZIP ' f Y CROSSSTREET � V APN 055— 25Q— Z� PARCELSIZE oS OWNER NAME PIIONE.- OWNERADDRESS, roe r CITI'/STATE/ZIP CONTRACTOR �jfi- 1:_cS� n f L G 1,.-- PHONE I O CONTRACTOR ADDRESS (Q CITY/S'1'A'1'E/ZIP ✓✓`^ K�/'�/J' l/� SUBCONTRACTOR 717 1` PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP r L �r c LICENSE &45 7 ❑C-61 ❑D-09 ❑Other NUMBER ,1 -1 EXPIRATION DATE V GEOGRAPHICAL INFORMATION: Coordinates X Y Township _ Range Section 3' INTENDED USE omestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization 0 Public Water System O If scni rmm Owner: WatcrSysterrName C o.int N.me or one um r TYPE OF WORK - New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Ilolc ❑Other ❑Monitoring Well(s) numberofwclls ❑Soil Boring(s) numberrofbnngs ❑Geotechnical numberofburings ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal �-- ew Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push PointCJ Other Proposed Well Depth "a�ft Excavation�in diameter ❑Open Bottom 0154ravel Pack/Gravel Size in diameter 0 ❑Conductor Casing in diameter / Conductor Casin Depth —N Well Casing Diameter �in Thickness/Gauge/ASTM Sched 7 S ❑Steel Wlastic 0 Stainless Steel ❑Other Grout Seal Depth�'-�R ❑Neat Cement(94 lb hug/5-10ga/water) ❑$and Cement fit .rack mix/7 gal water ❑Bentonite(20e/ solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method umped ❑Fr Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Insta ed B Tiller ❑Pump Co tractor ❑Other onerete Pedestal Dimensions: Width ft Length 8 ft Thick �. in ❑Christy Box 0 Stove Pipe PUMP $$(bmersible ❑Turbine ❑Other HP Pump Set it Standing Water Level it WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack Cl Dressed ❑Other Well Diameter S in Total Depth ZZ it Depth to Water ft ❑Casing to be Perforated,from ft to A Sealing Material ❑Neat Cement(94 lb hag/5-10 gal water) ❑Sand Cement .suck mix/7 gal water entonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑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 COMPENSATION LAWS. M IN IMYUM -/24 OUr7R'ADVANCE NOTICE REQUIRED FOR /INSPECTIONS—PLEASE CALL(209)953-7697 _ SIGNED I A/s-� ✓`�./l ia� TITLE �L'l/�U �- DATE �` It 1 - It, 2,46 4 _ DEPARTMENT USE ONLY Application Accepted B Date 1 "1 ''U> Area_ Employee ID# Z' (iroG�d4pection Date lQ ❑ SPECIAL Well Permit Pump Inspection By n <�- to (9 �� ❑ WAIVER Received Destruction Inspection B ate Constructed Well Depth ft COMMENTS t ,S PE Sc Received heck#/ Amount Date ermil Invoice Well IDN Codes Info By Remitted Service Request N Igo ,, Z7 7 $ 0- 43Xti So o � '- 4364 0( 0 S l EHD43-02-006�aaM On DA MASTER WATER WELL PERMIT,