SR0081892 SSNL - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMIT SAV JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"FL-STOCKTON CA 95202 -(209)468-3420 NON-REFUNDABLE //PERMIT --C--ALL/2+09 953-7697 FOR INSPECTIONS EXPIRES I YEAR FROM DATEISSUED JOB ADDttEss C9'f�� ! - .S (r2.-1�/1�EJ.i7�� CCITTY/ZTP�'7, 'le�� /3 O q CROSS STVEET f1+�GR y TV�4, APN 00 i,/..]'W PARCLI.SIZE OwnERNAMs tSu`D�Li �Q�Er�s�2rclL �- +4- ,ens— 7'.Q-- PHONE OWNER ADDRESSA 1 CtTY/STATFJZIP CONTRACTOR ta�A)� JT� . IIVL ' PHONE CONTRACFORADDRESS�/�+`t_ ,,^J`GG� Irl-Y/STATEIZIP ,v C SUBCONTRACTOR !S-'* Jl'Cr PHONE SUBCONTRACTOR ADDRESS, CITY/STATFJZIP LICENSE -57 ❑C-6l ❑D-09 ❑Other NUMBEREXNRATION DATE GEOCRAPHICAL INFORMATION: Coordinates X Y Township Range Section [iNTEM/EDUSE d DomeslirJPrivate O IrTigation/Agricultural O Industrial ❑Water Quality Monitoring Soil Ssmpling/Characieriation 0 Public Water SCRI S HaitreRnt rr�m ecu Dem sme C4iilatt sme o: neN..b. TYPE OF WoR.: O Nev,Wcll 11 Repleccment Well ❑Well Alteration/Mudi Frcation O Test Hole ❑Other O Monitoring Wells) _ mbeof llf ti 'totechnipl�Z n.beof borin sO 11 Well Destruction ❑Out-OfService well Q Out-Of--Service Well Renewal O New Pump ❑Pum Replacement ❑Pump Repair O Cross-Connection Repair WELL CONSTRUCTION Drilling Method O Mud Rotary ❑Air Rotary 1-211ku O Cable Tool ❑Push Point ❑Other Proposed Well Depth—2,j ft Excavation in diameter ❑Open Bottom 0 Gravel Pack/Gravel Size in diameter ❑Conductor Casing in diameter Conductor Casing Depth ft Well Casing Diameter_in Thickncss/Gauge/ASTM Schcd ❑Steel ❑Plastic ❑Stainless Steel El Other Growl Seal Depth ft ❑Nut Cement t^➢4Ih bagl5-10gal wore,) O Sand Cement xaGi miu/7 gal water ❑Bentonite(20%solids) ❑Manufacruier Spec%solids % Name_ ❑Spun on File ❑Specs Submitted Gmut Pla¢emeal Method ❑Pumped Q Free Fall ❑Other ❑Retrrdant/Accelerator(name) CA PEDESTAL Installed By ❑Driller O Pump Contractor ❑Other ❑Concrete PtdeNal Dimensions: Width_ ft Length ft Thick in ❑Christy Box ❑Slave Pipe PUMP D Submemible ❑Turbine ❑Other HP_ Pump Sol R Standing Water Level R WrLL DmRuenON D Open Bottom ❑Gravel Pack 0 Uncased ❑Otha Well Diartxter_in Total Depth fl Depti�to Watrr ft ❑Casing to be Perforated from it to Sealing Material ❑Neat Cement(94 1b bag/J-10 gal wnrer) ❑Sand Ccnlent salt mix/7 gal water >f:Qentonite Pell��DE S ❑Brntonitt(20°/solids) ❑Manufacturer Spec%solids _4o Name ❑Specs atI Fik ccs Su Placement Method O Pumped ❑Free Fall ❑Other ❑Complete with Mushroom Cap — R below grade ❑Complete to Existing Surface Pad I 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND TIL4T THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINAN S, STATE LAWS AND RULES AAD REGULATIONS, I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT D ACTIVE WI THE CALIF VIA CONTRACTORS STATE LICENSE BOARD AVD THAT I AM IN COMPLIANCE WITH ALL WORKERS MPENSATIO WS M IMUN!24 U ADV CE NOTICE REQUIRED FORRII�N�SPECTIONS–PLEASE CALL(209)953-7697 '/ SIGNED �- TITLE /-y}-r—P'- i�[ —� DATE y 005 03 Qp K Q K 1 s SEo.` 4N PIAL t j o t 0+ cut «..mutt to -- _ DEPARTMENT V ON Y ,r Application Accepted By Y Date Ci Arca 2. f Employee II)k O/T Grout Inspection By Doe Q SPECIAL Well Permit Pump Inspe,:tion By Date ❑ WAIVER Received tie eieirerf Inspection By �l..,L_� G Constructed Well Depth ft COMMENTS 'Fi GAJ�`� �g /tet")��'�'�, lGlt� CJc6�/ lf•94 �sTi/sr� Y /NirrCt.O,'i ft7/Eslyr PESC Recdved Amount Doh Permit/ Invoker Well IN, Codes Info B Cash Rcmined ServiceRequest 0 a 53 4 5 EHD 43-02-006 12/6n002 MASTER WATER WELL PERMIT