WP0038351 - Laserfiche WebLink

Home Browse Search

J WELL / PUMP PERMIT IIt SAN JOAQU N COAD'.-IY EM lROtia3E7,TAL HEALTH DEPARTMENT 608 £.4sT 3!Alti STRELT • SToc%Tor CA 93202 - (.199)468-3420 YON-REFUdDABL£ PERt91T tj EXPI/R�EjSj 1�Y'E,AR FROM DA ISSC .D 'JOR ADDRESS CROSS STRELT //7A >--q 3�i� D �• / - d l CP.ARCEEEL` SIZE a 014'NER N.%stE � /✓/^/ (i 7/ � i /�/ / _�� _/17�LV �Ip �. j��its�E�I OWN"ADDRESS '/t • I�`��/ L� Ci-T/1yf/D�T'.TEEMP M Com% G C0NTR.1Cr0R • /'W✓ !IV � G.r / L -Y PRONE -57 CO.\TR4Li OR ADDRES(i IO �D�+' �+v CIiY:S'rATEMj- StibCOTTRACTOR SUBCONTRACTOR ADORFSS LicEnsE ❑ C-57 W-11 1 ❑ D-09 II Otbcr N! IBER SG'7�fR1� POONE GEOGRAPDICALINioR411TlON: Coordinates X —.� Y --_..y-- Townslitp, — Raage Section - INTEADED USE ❑ Doomstic-Privat,- tioaiAgricutttuai ❑ industrial C Water QuaLity llaiiwing II Soii Svtgtting-Cha*.mr�rr t♦1 ❑Public Weser : as . Ifdifiaterhec: Ram:: w':Ca Sitirm �aaa Cccta V:mc n-1'i�er. tiv M:: L EIVED 11Pr Ut »ORr— ' 'vow w.(( U Reptac.'ruent well u well Alt.^ralion 4lodatication U Tcs£ Bole U Gttt r- - p AY 2 4 2019 C3Monitoft Wells) 61°4I `fw`t E3%.Bed". si r'Mbcr,.f w m, 13Geotechnictt° .. O Well Destruction ❑ Qui -0f Saniee wall D OuMM-Scn ice Well Renewal ❑ Bentonito (1» olids) II rw Manufac:uSpec �s solids ^ o \cA, Puw ❑ Pw Rypl.cenient ❑ Partin R. it ❑ Cross -Connection Repair PF:nEsT.%L Installed By 0 SRii[er 0 Rump Couttactor E N TA L I I I'.: l . I I 1 WELL CON IDN D Thick in ❑ ChrlstA° Bus d Slave " Pt'NP sbnmiblc ' urbiru ❑Other FP PumPSet it Standing\MauerLe:-el R WELL DLSTRc"CTION Q Open Bottum A Gralel Pack e7 Vncascd DrBite=.tiethad Method ❑ Ntud Rwery� O Air Roury ❑Aug,. -r t7 Cabk Tool ❑ Push Nim R Odfer— Sealing Materiar ❑ _vcat Ceutent (94 lb bag. 5-lagal nareq O Sand Cement A RT M El� I i HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND TA,AT THE WORK WILL BE DONE LV ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. STATE LAWS. AND RULES AVD REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRE?7 AND ACTF" WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM LN COMPLIANCE WITH ALL WORKERS CID SFGrtEn TITLE O4(/�---�C/ '' DATE- vete nc t i Date Area E ! Inspection By Bale ® SPECIAL Well Permit A PumpincpecttonBy4.� hate E3 WAIVERRece9Ved D:struction Inspection By — Date Constructed Well Depth _- i( (t.. rtu v�vcvw rrt-n Well Permit and Deccan m dux: 9!t s -2007 Proposed Well Depth R Exca'Vion in diameter D Opcn Botim U Gravel Pack, Gravel Sill in diamcw 13 Conductor Casing in dianvater i Conductor Casing Depth ^ ft Well Casing Ditater_i¢ Thickass' Gauge+AST1Saud ❑ Ssel ❑Plastic ❑ StaiNW�, Steel u Other Grout Seal Depth ft ❑'•:cat Ccmentt94tbbag.'-;,/rgaJnurer} 0&ndC.murs sack mix%7gaiwater ❑ Bentonito (1» olids) II rw Manufac:uSpec �s solids ^ o tanx ❑ Spas on Fi(: ❑ SluxsSubmits. Groat Placement fethod 13,Z- 'd ❑ Free Fall ❑ Other 0 Retardant,, Acc-Wrsmr (panic) _ PF:nEsT.%L Installed By 0 SRii[er 0 Rump Couttactor Cl QUzr _---�„_ - ❑ Concrete PedesW Dimensions: Width_._ ft Lcueth— D Thick in ❑ ChrlstA° Bus d Slave " Pt'NP sbnmiblc ' urbiru ❑Other FP PumPSet it Standing\MauerLe:-el R WELL DLSTRc"CTION Q Open Bottum A Gralel Pack e7 Vncascd D Chf= Wel( Diameter_ in Taal Dsptb—,_ A Depth to Water — A ❑ Caszr to be Perfmwd from A to ft j Sealing Materiar ❑ _vcat Ceutent (94 lb bag. 5-lagal nareq O Sand Cement SQCF: mt4 i 7 gal water Q Bentonite Pellets i ❑ B.ntorMc 00% solids) 0 Manufacturr Spic % solids °o knave ❑ Specs on Fdz ❑ 5;wc SubmiDed � Placelaeat ltletbod ❑ Pumped ❑ Free Fail CI Other ❑ Can le•.e with Mushroom Cap ft beiow grad2 ❑ Complete to Existing StLrfk-- Pad i HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND TA,AT THE WORK WILL BE DONE LV ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES. STATE LAWS. AND RULES AVD REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS CURRE?7 AND ACTF" WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM LN COMPLIANCE WITH ALL WORKERS CID SFGrtEn TITLE O4(/�---�C/ '' DATE- vete nc t i Date Area E ! Inspection By Bale ® SPECIAL Well Permit A PumpincpecttonBy4.� hate E3 WAIVERRece9Ved D:struction Inspection By — Date Constructed Well Depth _- i( (t.. rtu v�vcvw rrt-n Well Permit and Deccan m dux: 9!t s -2007