SU0008549 - Laserfiche WebLink

Home Browse Search

WELL 1 PUMP PERMIT SAN JOAQUIN COIJNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95702 -(209)468-3470 NUM-REFUNDABLE PEE,RMITU CALL�y 22j099))9."--76917 FOR INSPECTIONS EXPIRES 1 YEAR rFROM DATE ISSUED JOB ADDRESS I� / -,/ L..1/W4t� JWI,efL men CITY/ZIP (�d JIf �"�'�✓ CROSS STREET �Q j AP, fi(S 2 •�r—�+ PARCELS#= 7 �•I/•/_ OWNER NAME �`✓T� PRONE .20-79 OWNER ADDRESS CrTYIS7ATPJLIP_46111 till ` rpylnNE CONTRACTna -313�T,y/♦ CONTRACTOR ADDITE �o CTTYISTATFIZIP lCJ t/w[.1, SUBCONTRACTOR PHONE SUBCOMRACTORADDRESS CITY/STATFILIP �/•1 fry Jf LICLNSE [3C•57 C-6l 0.09 Q Olh![ r.to F NUMBER f( EXPIRATION DATE r-+ i13 GEOCRAPHICALINFORMATiON: CoardknateT X Y Ta*nsll Range Section INTENDED USE KDomcsIiUPl ❑Irrigation/Agricultural ❑Industrial ❑WuerQuahty Monitoring ❑Soil Samplingloaractorialion 13 Public Witter Srem WWII we Dombwr+:' neo Nph mr uu .eneor u+n Pq TYPEOF WORx R New Well ❑Replacement Well O Well AherationlModificalinn ❑Test Hole o Other ❑Monitoring WCII(s) mamherorwelis ❑Soll Boring(s) amber or i ❑Geotechnical numberol'Wrinp ❑Well Destruction CI Out.OFSorvice Well ❑Oul-0f--Service Well Renewal ❑New Pum m Replacement ❑Pump Repair ❑Cro_Ss-Connection Repair WELL CONSTRUCTION ^ Drilling Method ❑Mud Rotary O Air Rotary d Auger 0 Cable Took o Push Point O Other Proposed Well Depth ft Excavation_ in diameter ❑Open Bottom 0 Gravel Pack I Gravel Sias JR diameter ❑Conductor Casing in diamernr I Conductor Casing Depth fl Well Casing Diameter_in Thickness/OaugelASTM Sched ❑Steel C3 Plastic ❑Sleinlesa Steal (3 Other Grout Seal Depth n O Neat Cement(94 fh hag/3-10 gal water) Cl Sand Ccmcnt sack mir/7 gal water O Bmtoniee(20%solids) 0 Manufacturer Spec h solids % Name _ ❑Specs on File O Spa&Suhmined Grout Placement Method O Pumped ❑Free Fail ❑Other_ ❑Retardant I Accelerator(name) R PEDESTAL Installed By ❑Driller Cl Pump Contractor C3 Other ¢ 0 Concrete Pedestal Dlmenstoaa: Width_R Length it Thick in ❑Christy Box Q Stove Pipe PUMP Submersible ❑Turbine ❑Other 14P,3M. Pump Set tl Standing Water Level _n ,• WELL DESTRUMON O Open Bottom ❑Graves Pack Q Descried Q Other Well Diameter in Tonl Depth n Depth to Wall n ❑Casing to be Perforated from fl in n Sealing Material ❑Ncet Cement(94 Ih hug I5-10gar!wooer) ❑Sand Cement sack mix/7 gel water O Bcnlanita Pellets 0 Bentonite(2010/,solids) O Menufamurcr Spec%solids % Name ❑Specs oa File ❑9poca Submitted Placement Method ❑Pumped O Free Fall ❑Other I ❑Camplcte with Mushroom Cap it below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DON£ IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIPY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRAL-FORS STATE LICENSE BOARD AND THAT l AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. MIN UM 24HjRAD)V4WCll CE REQUIRED FOR INSPECTIONS—P�L£ &E CALL 209)953-7697 SIGNED TITLE J01 O N NN ON f5 r � DEPARTMENT USS ONLY s Application Accepted By 1 Date Arcs Employer IDN Gro wInsptctivaBy Date ❑ SPECIALWell'Persi pump, nate ❑: WAIVER Received prratntctian Inspection By Date Constrereled Wall Depth R COMMENTS PE Sc Received Cheekls! Amount Permit! Codes Info B Cash Remitted Date Service Request 0 Invoice WNIrDN El 43-024)06 MASTER WATER WELL ii 121612002