SU0003582 - Laserfiche WebLink

Home Browse Search

W LLL / rujur rEluvil I SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEP MENT 304 E WEBER Avt�'FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT t- LL(209)953-7697 FOR INSPECTIONS E; ;FRES 1 YEAR FROM DATE ISSUED JOB ADDRESS S \ CITY/Z1P y 1 v CROSS STREET / '� D"r�"1"` APN l ( �`�- I__ PARCEL SIZE r m Lf: OWNER NAME 2-Q y / {oYr� PIIONE f 5 q5,36-4 � 3/Y�5 OWNER ADDRESS �b{,�,c 17 1 Ij�t (f T Ob1\1 - CITY/STATE/ZIP��ayj C1.a "J 5 3 6.4 CONTRACTORG il'r Y +/a ✓ /�n d I �7 _ P ONE ZD �S 7 S3_ f !(� �1 Q CITY/S-1 / n R(>[ ATEIZIP �� '9C©� CONTRACTOR ADDRESS 2D�2 I U y - v' SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CrrV/,STATEIZIP {' LICENSE ❑C-57 ❑C-61 ❑D-09 ❑Other NUMBER EXPIRATION DA•1'E V 1 GEOGRAPHICAL1NFORMATION: Coordinates X Y Township Range Section INTENDED USE C1Domestic/Private R Irrigation/Agricultural 11 Industrial ❑Water Quality Monitoring ❑Soil 5amplinglCharaclerizatian ❑Public Water System If different from Owncr: ater ystem amc antact amc ar ' one um er TYPE Or WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification Test Mole ❑Other number of wel Is WPU,'5,hPoint number of borings ❑Monitoring Welt(s) ❑Soil Boring(s) echnical ❑Well Destruction ❑Out-Of-Service Well PbRep t ❑New Pump C]Pum Replacement ❑Pum Repair i WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool Ot er Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack 1 Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic Q Stainless Steel ❑Other Grout Seal Depth ft 0 Neat Cement(941b bag/5-l0ged wafer) ❑Sand Cement .ruck inix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name 0 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 ft Length ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level tt WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Well Diameter in Total Depth ft Depth to Water 11 ❑Casing to be Perforated from ft to ft Sealing Material ❑Neat Cement(941h bug/5-10 gal wafer) ❑Sand Cement suck inix/7 gal water ❑Bentonite Pellets 0 Bentonite(200/.solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap I't below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT l 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. MINIMUM 24 HOU ADVANCE NOTICE REQUIRED FOR INSPECTIONS /f 7 SIGNED TITLE DATE 'r 1 f y\a l rU II .-n I I I A —L4 I J\ i DEPARTMENT USF/ONVY Application Accepted By Date ( Area Employee IDM -- Grout-Inspection By Date ❑ SPECIAL Well Permit y Pump Inspection By Date ❑ WAIVER Received Destruction Inspection Bylr�l , Date Con' acted Well Depth ille oe A r COMMENTS PE SC Amount CI / Received Date Permit/ Invoice# Well ID# Codes Info Remitted ash By Service Request M a ) c= S 0 232 f EHD 43-02-006 MASTER WATER WELL PERMIT 5nn-002