SU0012228 - Laserfiche WebLink

Home Browse Search

WEL /PUMP PERMIT ` SANOAQUIN COUNTYENVIRONMENTAL HEALTH DEPARTMENT 0( 304E WEBER AVE 3-FL-STOCKTON CA 95202 -(209)468-34;1 NON-REFUNDABLE PERMIT CALL 2 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED 'r- �t Tic-,g-c� > JOB ADDRESS Z�i�r'�B-((N]rjQy� �r��- ri�7r2�!.�1¢''1/ CRY/ZIP � CROSS STREET ,aT y� l APN ZG'i(] Z ( PARCELSIZE OWNER NAME l l. �'., �:-ff. -�L� PHONE OWNER ADDRESS i' "4 CITY/STATE/ZIP CONTRACTOR PHONE CONTRACTOR ADDRESS CITY/STATE/LIP ` I SUBCONTRACTOR IG-l��.��i� PHONE SUBCONTRACTOR ADDRESS -Z$-75;-- /2rr1/ 'CRY/STATE/ZIP 09 -� LICENSE C-57 ❑C-61 ❑D-09 ❑Other NUMBER 741"2 S Z- EXPIRA'r10N DATE GEOGRAPHICAL INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring ❑Soil Sampling/Characterization ❑Public Water System onu"i nmeor onr um r Ifdiffc=t from Own- TYPE OF WORK ❑New Well ❑Replacement Well ❑Well Alteration/Modification ❑Test Hole ❑Other numb—l'bunn ip ❑MomIoringWell(s) numberorwcus t7 nambrrorbonny, ❑Geotechnical Soil Boring(s) N' ❑Well Destruction ❑Out-Of-Service Well ❑Out-Of-Service Well Renewal 1 ❑New Pum2 O Pump Replacement ❑Pump Repair ❑Cross-Connection Repair �6 CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary Auger ❑Cable Tool Push Point ❑Other Proposed Gat- Depth ft Excavation in diameter ❑Open Bottom C1Gravel Pack I Gravel Size in diameter ❑Conductor Casing in diameter / Conductor Casing Depth 11 ' Well Casing Diameter_in Thickness/Gauge/ASTM Schad ❑Steel ❑Plastic ❑Stainless Steel ❑Other Grout Seal Depth It ❑Neat Cement(94 lb hug/5-10 gal wider) ❑Sand Cement .ruck mis 17 gal water ❑Bentonite(200/solids) ❑Manufacturer Spec%solids_% Name ❑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_fi Length_ft Thick in ❑Christy Box ❑Stove Pipe PUMP ❑Submersible ❑Turbine O Other HP Pump Set It Standing Water Level ft 4 '�E DESTRUCTION ❑Open Bottom ❑Gravel Pack O Uncased ❑Other Well Diameter in Total Depth 11l Depth to Water ft ❑Casing to be Perforated from ft to mNL-ft Sealing Material Neat Cement(94 Ih&,9/3-10 gal wurer)EP'(5❑Sand Cement .sock mix 17 gal water Bentonite Pellets Gr+ a/��S/ ❑Bentonite(20%solids) ❑Manufacturer Spec%solids_% Name 13 Specs on File ❑Spet tSubt?' Placement Method ❑Pumped ❑Free Fell ❑Other ❑Complete with Mushroom Cap ft below grade ❑Complete to Existing Surface Pad I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY UIRED IS ICENSE CURRENT AND ACTIVE ORDINANCES, OCERTIFY WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARDAND THAT I AM IN COMPLIANCELWITH ALL WORKERS COMPENSATION LAW ;?4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS TITLE DATE SIGNED IUr�v�s ,2— a z_ IP AN JO C �� Date Z- Area_ FmployeeID ;_ Application Accepted - l�VQ Dare ❑ SPECIAL Well Permit Grout Inspection y Pump Inspection By Date ❑ WAIVER Received Date Constructed Well Depth ft Destruction Inspec ion y 1 COMMENTS Z r PESC Amount hec Received Date Permit/ Invoice# Well ID# Codes Info Remitted ash By I I Service Re nest# EHD 43-02-006 V MASTER WATER WELL PERMIT 5n2002