SR0082194 SSNL - Laserfiche WebLink

Home Browse Search

-- -- - WELL/PUMP PERMIT ' SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBER AVE 3"'FL-STOCKTON CA 95202 -(209)468-3420 NON-REFUNDABLE PERMIT CALL. 209 953.7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED /ZIP L.� qsa Via- M JOI ADDRESS CITY 59 o K� d 0 ►K I Y (} 1U� - y CROSS STREET __..____- APN V�-�' T - I - PARCEL SIZE 2-7, `� L p 1 1 �,X9 00 OWNER NAME PILON OWNER ADDRESCITY/STATIZIP CONTRACTORWIST VICi/) I- PHONE� y363 �35Q � CONTRACTOR ADDRESS � 1, L-*jfj CITY/STATE/Z11 (.t)16 �S1U SUBCONTRACTORNf N ,, P`IIONE _ !iG SUBCONTRACTOR AADDttRE>S>1L�eLA- CITYISTA7'E/ZIY LICENSE 13C-57 'OC-61 0 D-09 13 Other C'1U-4a ► NUMBER /43 EXPkRAT10N DATEU� `� 0 GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Sectlon INTENDED Use Domestic/Privatc ❑Irrigarion/Agricuktiral ❑Industrial ❑Water Quality Monitoring ❑SOiI Sampling/Charneterizauon I ❑Public Water SYMEM Irdimm.,from Owner. Waler Syucrn Namc unracr anu or wnc.um •r TYPE OF WORK ❑New Well ❑Replacement Well G Well Alteration/Modification ❑Tat Hole ❑(`cher ❑Monitoring Well(s) number of wills ❑Soil Borin g(s) numberoft'"ings 0Gcotechnioal ^umbrr of barmy ❑Well Destruction C Out-Of-Service Well ❑Out-0f--Service Well Renewal New Pump 0 Pump Replacement O Pump Repair ❑Cross-ConneC Lion it WELL CONSTRUCTION Drilling Method ❑Mud Rotary ❑Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other Proposed Well Depth 11 Cxcawtion _in diameter ❑Open Bottom ❑Gravel Pack IGot vel Size-.-— diameter ❑Conductor Cving in diameter / Conductor Casing Depth _I1 Well Casing Diameter_in Thickness/GaugelASTM Sched ❑Steel 0 Plastic 0 Stainless Steel ❑Other Grout Seal Depth_ ft 13 Near Cement(94 lb bag/540 gut wrner) 0 Sand Cement suck mrz/7 gal water El Bentonite(20°/solids) ❑Manufacturer Spec%solids_% Name Q Specs an File ❑Specs Submitted Grout Placement Method ❑Pumped D Free Fall ❑Other ❑Retardant/Accelerator(name) PEDESTAL Installed By to Dnller ❑Pump Contractor! ❑Other ❑Concrete Pedestal Dimensions: Width ___ it Length ft Thick in 0 Christy Box ❑Stove Pipe (submersible OTurbre, ❑Other_ Hp-y?,- Pump Set 8 �— PUMP ¢d ti Standing Water l.evcl 71 WELL DESTRUCTION ❑Open Bottom ❑Gravel Pack ❑Creased ❑Other Well Diameter in Total Depth _It Depth to Water ft ❑Casing to be Perforated liam__ft to A Sealing Material ❑Nat Cement(94 lb brtg/5-/0bw1 wnrer) Q Sand Centent sack mix 17 gal water ❑Bentonite Pellets 0 Bentonite(20%solids) [3Manufoc[urtr Spec%solids % Name _, Specs on File ❑Spxs Submitted Placement Method ❑Pumped O Free Fall ❑Other 0 Complete with Mushroom Cap ft below grade O Complete to Existing Surface Pad I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN IOAQUIN COUNTY ORDINANCES,STATE. LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKERS COMPENSATION LAWS. / I�/jl�/t'��f(T//��//JQ MIN UM 24 O ADVANCE NOTICE RR�E�QLLI/RED FOR INSPECTION' SIGNED lid" / � .�� TITLE /1[/_.__L/� �.- ffi/c. ATE _ L: t N J /<C ut, �� p ,, DEPARTMENT USE ONLY Application Accepted By� �� V Date 9 - Area _ Employee ID# Grout Inspection By _ Date E3 SPECIAL Well Permit Pump Inspection By Dare 8 Z_ ❑ WAIVER Received Destruction lnspceti n By .,..','.. Dare Constructed Well Depth 11 COMM fNTS — ..— PE SC Amount Chrc / Received Permitt Invoice tY Well IDq Codes into Remitted -ash By Date Service Request p 3 50 n,j ICOME EHD43-02.006 MASTER WATER WELL PERMIT 5/712002