SU0003891 - Laserfiche WebLink

Home Browse Search

fj WELL / PUMP PERMIT SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH CP%,RTMENT 304 E WEBER—v53-FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS ��-/ L� j_�//)(r" y1/1 G a.�_ CITI'/ZIP �jI_, •/'�j �--� .p _ v CROSS STREET b ` T APN t RJM1J O PARCEL SIZE ��- C- c R OWNER NAME _ � r t' � PHONE: 9 OWNER ADDRESS CITY/STATE/ZIP 01 CONTRACTOR PHONE , f- ��Y� CONTRACTOR ADDRESS CITY/STATE/ZIP O QHS SUBCONTRACTOR PHONE SUBCONTRACTOR ADDRESS CITY/STATE/ZIP LICENSE -57 C-61 ❑D-09 ❑Other NUMBER :3�2 ;?d!7ro EXPIRATION DATE Q 3 L GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System If different from Owner: Water System Name Contact Name or Phone Number J M 11111111 OVA 1111% a TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑T H I ❑ he r a- number of wells number of n {4�--�' number of borings El Monitoring Well(s) 13 Soil Boring(s) Geo hR4h Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION C Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth ft Excavation in diameter ❑Open Bottom ❑Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth ft Well Casing Diameter in Thickness/Gauge/ASTM Sched ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth ft ❑Neat Cement(94!b bug/5-l0 ga!water) ❑Sand Cement .ruck mix/7 gal water ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) 7� PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other C ❑Concrete Pedestal Dimensions: Width ft Length ft Thick in ❑Christy Box ❑Stove Pipe z PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level it WELL DESTRUCTION ❑O en Bottom ❑Gravel Pack ❑Uncased ❑Other P. v Well Diameter in Total Depth _ ft Depth to Water—9-47ft ❑Casing to be Perforated from tt to ft Sealing Material ❑Neat Cement(94 1b bag/S-10ga!water) ;&Sand Cement_ sack mix/7 gal water ❑Bentonite Pellets ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped IN Free Fall ❑Other 2LComplete 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. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. 24 M=1HOUR VAN NOTICE REQUIRED FOPECTIONS— PLEASE CALL(209)953- 7 MI SIGNED TITLE �1 DATE lei AC Up I I - � P 6L1 H L7 SE VIC DE PA T NT USE ONLY C1 Application Accepted By � ll U_T�l1T'�`'v Date 0 3 Area Employee ID# 54 Grout Inspection By Date ❑ SPECIAL Well Permit Pump Inspection By Date ❑ WAIVER Received Destruction Inspection B Date ��Z��3 Constructed Well Depth ft COMMENTS PE SC Received tk# Amount Date Permit/Service Well ID# Codes Info By Cash Remitted Service Request# 4T3 N1 MASTER WATER WELL PERMIT EHD 43-02-006 12/6/2002