SU0012228 - Laserfiche WebLink

Home Browse Search

t WELL I PUMP PERMIT SAN JOAQ01 COUNTYENVIRONMENTAL HEALTH DEPARTMENT 304 F W'FDF.R AVF 3—Fl.-1TOfKTON CA 95202- (209)4611-3420 NON-REFUNDABLE PERMIT CALL 209 953.7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED JOB ADDaFsc CROSS STREET _ �'W Y �"Q AP\ r+C.G! —Ci -Z� PART FL SI7E r OWNER NAME. �l G P NE aZJ OWNER ADDKE53 _ _ -__ CITY/STAT!/ZIP r CON TKALI OR �( /t _ j �j r[ ,�"L- AA/ PIIONEF)!; CONTRACTORADDRL'4r s!/j _ I CrrVlSTATFJ%I►__�� SCRCONTRACTOR PHONE SLBCONTRACI O R.A DDRUM Crri'M AILIZIP LICENSE ❑C-57 O C-6I ❑D-09 Othe' 2 NUM6ER EXPIRATION DATE � GrOCRAP111CAL INFORMATION: Coordinates X _ _ Y Township Rea=c Sectio- INTENUED USE ; Dlfiuuic/Pnvate ❑IrrigatitiWASFu:ultuml ❑Industrial D Water Quality Muniturmg ❑Soil Sarnpling/Characterlration ❑Public Water Srsrenr If di if—,from Dwrrr ton roam N.— �R.ms TVIF.OF WORK ❑Nc.We:: ❑Replacement Well O Well Al-lranon/Moditicauun ❑Test Hole ❑Other ❑Mori—ring Well(,) _ mmO Or+cels 0 Suil Iluring(s) -mbn urbonnp O G o.c7hwc-1 rawalierafaedrys ❑Well uestracuun ❑Out-O(-Service Well OOut-OI'-Scrvicc Well Renewal ❑New Pump O Pump Rcplw:t=m ❑Pump Repair -rots-Cunnec lion Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool O Push Pu:et ❑Other Proposed Well Depth_ _ It Lncava:ion in diameter ❑Open bottom ❑Gravel Pack/Grovel Size _in diamctct ❑Conductor Casing m diameter / Conductor Casing Depth _ Web Casing Diameter in ThickncsslGaugc'ASTM Sched ❑Steel ❑Plnslic ❑Stainless Steel ❑Other 11 Grout Seal Depth fi ❑Neu C'emen:(p4(h Aug/S-!0 gut worry/ 11 Sand Ccmcm __rcrck mix;7 gal water ❑Bentonite(200.5 solids) ❑Manufacturer Spa Y.solids_ry Name_ ❑Specs on File ❑Spm Submitted v V Grout Placemeart Method O Pum ped ❑Frcc Fall ❑Ott., ❑Rcurdsr.t/ACccICral6r Ir.ame) _ PEDt'srAL Installed By ❑Driller ❑Pump Contractor ❑Onccr_ _ 'y- ❑Concrete Pedcual Dimensions: Width_ 9 Length_ti Thick in ❑Christy Bos ❑Stow Pipe Purr u6.:.erstble ❑Turo:ne ❑Ocher HP Pump Ser it Standing Water Level it WELL DLs:rRVCnON Cl Oper.Bottom 13 Gravel Pack ❑Lncascd [I Other _ Well Diameter in Tota!Dcp[S It Ik-pth to Wtrrr Il ❑Casing to be Perforated from rt to h Sealing material O Ncat Cemrnt I9J IA h.+y/S-lOgul wurrr) ❑Send Ceiricnt cock nrir?7 i{ul-ata O Bentonite Pellets ❑Bentonite(2(%solids) ❑Manufacturer Spec%s-lids__.! Name ❑Specs on Ede ❑Spec3 Submitted Placement Method ❑Pumped El Free Fall ❑Oncct_ ❑Complete with Mushroom Cap __ __ it below grade ❑Complete to Fxisting Surface Pad 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 7 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. RI hjflV�ti1USUR ADVANCE NOTICE REQVIRED FOR!� PECTIONS—PLEASE CALL(209)953-7697 _ SICNED�''lJ'a.}r/2.>• ✓XJ'"i l TITLE DA7 F. 41 .'�7� fir( AN 1 I r O IN DEPARTM ENT USE qNIY S Applic tion Acepted By ,`•— __-_- Datc 4, Arca .z/ (o F.mpluyce IDa /4SL' /q Grout Inspection By Dale ❑ SPE(7AL Well Permit Pump Insper-•tion By ' � Date1Z__ �.:/_ ❑ WAIVER Received uotructiun Irspxction By Dan: Constructed Wall Depth—_It COMMENTS PE SC Received Ch Amunt Permiu Codes Info 8 C. Remirted Date Se"ke Request a Invoice K Well IDP.' —_ 4s 7? G O sL tom) EHL)43-02-006 MASTER WATER WELL PERMIT