SU0012659 - Laserfiche WebLink

Home Browse Search

WELL / PUMP PERMIT SAN JOAQUIN(.Oljl%'TY ENVIRONMF.NTAI.HEALTH DEPARTMENT 304 E WERFR AVE 3""FL-STOCKTON CA 95202 - (209)468-3420 NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATF. ISSUED LA JuaADDRESS A \ / �._ _. CrIVzII. > v CnossSrREEr ;] }`APN,� e9'7"033'0-/�oV PARCELSIZE _LAND USE APPLICATION# v OWNERNAME (� arJQD�r7/ C:ty7I�,�'I dGfL�I PHONE Ow74F.RADDRFSS ^�S7 dy Aj /4l k"o+ f` CITY/STATFJTIP SAClGL"Z CONTRACTOR /je ) r �A_F��C- PIIONF. � �� CONTRACTOR ADDRESS oC�o`J /✓L V Y'il'C Crrl'/STATE/ZIP C- S~ SUBCONTRACTOR PHONE SURCONTRACTOR ADDRESS CI`TY/STATE/7.11' n LICENSE -57 ❑C-61 ❑D-09 11 (V Other NUMBER 7 S EXPIRATION DATE �/ v GEOGRAPH)CA L INFORMATION: Coordinates X Y Township Range Section INTENDED USE ❑Domestic/Private ❑irrigation/Agricultural ❑Industrial ❑Water Quality Monitoring QlSoil SamplingiCharacterizltion ❑Public Water Syystem __ If different from Awner a:cr System Name -- ,,tact Name nr i-m um cr TYPE OF WORK ❑New Well ❑Replacement We]) ❑Well Alteration/Modification ❑Test Hole ❑Other ❑Monitoring Well(s) _ _ d of wells 0'oil Boring(s) u of borings PGeotechnical_ p of borings ❑Well Destruction ❑Ow-Of-Service Well ❑Out-OF-Service Well Renewal ❑New Pump ❑Pump Replacement ❑Pump Repair ❑Cross-Connection Repair WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary RAuger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth /O -/ it Excavation/,S_ in diameter ❑Open Bottom ❑Gavel Pack,Gravel Sire in diameter ❑Conductor(.rasing in diameter ; Conductor Casing Depth ft Well Casing Diameter in Thicknes,;A;auge/ASTM Sched ❑Stect ❑Plastic ❑Stainless Sted ❑Other Grout Seal Depth 1l ❑Neat Cement(94 lb bag/5-10 gal water) ❑Sand Cc m t sack.nix/7 gat water ❑Bentonite(20%.v 11Manufacturer Spec%solids_ % Name w OSpces on File ❑Spew Submitted Grout Placement Method ❑Pumped ❑Free Fall ❑Other ❑Retardant r Kiccelerator(name) PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑Other ❑Concrete Pedestal Dimensions: Width fl Length fl 'Thick in ❑Christ}'Box ❑Stove Pipe Pl1MP ❑Submersible D Turbine ❑Other HP Pump Set _ft Standing Water Level ft WELL DFSFRUCTION ❑Open Bottom ❑Gravel Pack ❑Uncased ❑Other Wel]Diameter _.._in Total Depth It Depth to Water ft ❑Casing to be Perforated from H to 13 Z Seating Material ❑Neat Cement(941b bag/5-10ga1 mater) ❑Sand Cement sack mix/7 gal water ❑Hentonitc Pellets � ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name _ ❑Specs on File ❑Specs Submitted Placement Method ❑Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap 19 below grade ❑Complete to Existing Surface Pad 1 HEREBY CERTIFY THAT 114AVF. PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE W1TI1 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 STA'I E LICENSE. BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKERS COM ENSATIOIV LAWS. A MINI-NqIV HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED �' t� TrmE DATE Ilk I 1K Nz FM HL Ll I C� J rt DEPARI-MENT IJSE ADI, Application Accepted By Date 6-3U n Area .21 _ Employee IDN 2Y!)c (.',Tout Inspection R Date-- ❑ SPECIAL Wel( Permit f� Y Pump Inspection By Date ❑ WAIVER Received Destruction Inspection By Date Constructed Well Depth ft COMMENTS PE SC ReceivedCheck# Amount Permit/ Date Invoice# Well ID# Codes info By ash emitted c e ural# 43.7 15c7 l—'I -W2-3(9-110 • . EHD43-02-006 MUSTER WATER WELL PERMIT 1222,2003