Laserfiche WebLink
1'a'7e11g11J , ' <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL H EPARTMENT 304 E WEBER AVE 3a 1 cxroN CA 95202-(209)46g-3420 �'(�+✓j�//�C�, r <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS EXP: S 1 YEAR FROM DATE ISSUED ✓j/ Dv JL �' <br /> �c <br /> JOB ADDRESS 6484 N. Waverly Road CITY/ZIIIP Lindin, 95236 �.�,/ i/r <br /> D <br /> CROSS STREETF1ood Road ApN 093-440-02 PARCEL SIZE 798LAND USE APPLICATION# ��06 <br /> OWNER NAME San Joaquin County PHONE209-468-3066 T <br /> OWNER ADDRESS 1810 E. Hazelton Avenue CITY/STATE/ZIP Stockton, CA 95201 ✓/C4 <br /> CONTRACTOR Krazan & Associates, Inc. PHONE559-348-2200 ...� <br /> CONTRACTOR ADDRESS 215 W. Dakota Avenue CITY/STATE/ZIPC10vis, CA 93612 <br /> SUBCONTRACTOR •`�'-" <br /> ��'�C PHONE 800-873-3073 <br /> - <br /> SUBCONTRACTOR ADDRESS9580 County Road 93B CITY/sTA7jzU,Zamora, CA 95!698 <br /> LICENSE XC-57 13C-61 ❑D-09 ❑Other NUMBER D V EXPIRATION DATE 10 1 <br /> �i,,O GG ! I/ �f b <br /> GEOGRAPHICAL INFORMATION: Coordinates X l� 5 3�' W Y S csl 31 F� Township_ Rang¢ Section_ <br /> INTENDED USE ❑Domestic/Private ❑Irrigation/Agricultural ❑Industrial V Water Quality Monitoring ❑Soil Sampling/Characterization Jp <br /> ❑Public Water System (- <br /> Ifditferent from Owner Water Sym.Name Comad Name orPhone Number <br /> TyPE OF WORK IoNew Well ❑Replacement Well ❑Well Alteration/Modification ❑Other <br /> ❑Monitoring Well(s)_g::__#of wells ❑Soil Borings) Pofbonog. ❑Geotechnical n of borings s�V <br /> Cl Out-Of-Service Well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> ❑New Pump ❑Pump Replacement ❑Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method ❑Mud Rotary /w Air Rotary ❑Auger ❑Cable Tool ❑Push Point ❑Other <br /> s <br /> Proposed Well Depthlq 15�25ft Excavation '2:5 in diameter 13Open Bottom M Gravel Pack/Gravel Size ' in-diameter <br /> @Conductor Casing 2i>6in diameter / Conductor Casing Depth 295 4 ZZ5 ft LD1IE.ST'Af{ <br /> rS Well Casing Diameter Z in Thickness/Gauge/ASTM Sched 40 ❑Steel OPlastic ❑Stainless Steel ❑Other <br /> Grout Seal Depth ft Neat Cement(941b bag/5-10 gal water) ❑Sand Cement rack mir/7 gal water <br /> aTr R M:LPIF lig ❑Bentonite(20%solids) ❑Manufacturer Spec%solids % Name ❑Specs on File ❑Specs Submitted <br /> _o Grout Placement Method Pumped ❑Free Fall ❑Other ❑Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑Driller ❑Pump Contractor ❑ Other <br /> ❑Concrete Pedestal Dimensions:Width ft Length ft Thick in ❑Christy Box J9,Stove Pipe <br /> PUMP ❑Submersible ❑Turbine ❑Other HP Pump Set ft Standing Water Level R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. 45 <br /> I NTU=ADVANCE NOTICE REQUIRED FOR <br /> /jINSPECTIONS <br /> SIGNED — - TITLE VC"� l"'t,�//1174ls...,• D. 6/Z7/0 6 <br /> 5k AN h 2—L t4i <br /> E <br /> DE A TMENT U E NLY <br /> Application Accepted B� ` Date Area Employee ID# <br /> Grout Inspection By ate ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Constructed Well Depth R <br /> COMMENTS <br /> PE SC Received Check# Amount Date Permit/ Invoice# Well H)# <br /> Codes Info B ash Remitted Service Request# <br /> o !23 0 <br /> EHD 4 7 412-006 WELL PUMP PHRMIT <br /> 1/27/2005 <br />