Laserfiche WebLink
Jun 16 16 10:20a Ken Gross Wells& Pumps 2097458584 p.3 <br /> ' WEL UPUMP PERMIT <br /> •SAN JOActuiN CouNTY EMARDN.VENTAL HEALTH DEPARTY ENT 1E68 FIST HAMITON AVENUE-SrocKTON CA 95205 •(209)46"20 <br /> NON-REFUNDABLE PERMIT CALL 209)953-7697 FOR INSPECTIONS EXPIRES i YEAR FROM DATE ISSUED <br /> 0-1 L _..i m <br /> JoeADORf55 `• \ Von4 Crrri�P 5cR_ <br /> n <br /> CROSS STREET \� APH ARLELSIZE-+1 13 LAND USR <br /> 10N <br /> A <br /> /'� m <br /> OWNER NAME +� —L, Q dd73zD�31 PHONE <br /> O WNER ADORES$ , ' L _ 7ATY/STATElLPZ�l l <br /> r <br /> CONTRACTOR L� n�'� t ( -- .� PHONE ✓��f <br /> CONTRACTOR ADDRESS 35� /V' �+1 FI-L l li/LfL CMISTATEM <br /> S.'4COMRACTOR. <br /> SUBCONTRACTORADDREss .__--_. ':rry STATFJZIP <br /> NSE O C-6t 11 D-09 n Other--.— Nrlm9ER ExPuuro^e DATE'-`' <br /> GsOGRAPMCAL INFORMATION: Coordinates K Y Township_ Range Sectlonf_ <br /> INTF.NOEDUSE ontestiCJPrivate C InigatioruAgricuitural 0 Industrial 7_Water QuaPyMonit3ring 7 Sol S9mp5ng/Charyctel'zaf6n <br /> U Public WaterSystem - ---- <br /> If diBemnt e°m Owner, — - a.er uyswm Nm e Corftoi F49=1 of PharC PlUrWf <br /> Tr a OF WORK jYfVew Well AR lacemenl Well C Well AlteationNod ficabon 0 Other_ J <br /> F1 MDndonng WeII{s) t of wells r Soil Boring(s) <br /> cr <br /> d of t0°' r-t Ge otechnil 3 d bcrinca <br /> O Out-Of-Service Well C Out-Of Service Well Renewal -i Cross-Ccnnacton Repair <br /> tyNewPumo �Pump Replacement C Pump Repair 7 Raise Well Casing _ <br /> WELLCOMSTRUCTION <br /> Drilling Method O Mud ry J Air Rotary =Auger ✓1.�able Tonl G Push Point C Other _ <br /> Proposed Well Depth ��- ft ca ,�O <br /> Exvation —W in diameter � pJ en Bottum Gravel Pa! /Gravel Size in dlarneier <br /> O ConductorCasing in diameter / Conductor JCasing Depth _it <br /> Well Casing Diameter (-in ThixknessrGauge/ASTM Sched / 1S ) 7 Steel -i Plastic ri Stainless St--PJ rl Other <br /> Grout Seal Depth �ft O Neat Cement(94 fb bag(5-10 gat wate4 /Sand Cement / "+� sadr m:xR gat crater <br /> ❑Bentonite(20%solids) 0 Other <br /> Grout Placernont Method 0 Pumped C Free Falt 1)�'Other Ik_Er " =RearUant l Accelerator(name) <br /> �-PEcEsTAL Installed By �Dulfer t Pump CordraCor�r Other in Christy Box Stnve Pip. <br /> !I Concrete Pedestal rDimensions:Width;]_ft Length ft Thick <br /> PUMP - ubmersinleo Turbine D Other HP Ftmip Sel _ft Standing Water Levet ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE LMORK WILL BE DONE IN ACCORDANCE WITH SAN (\U <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. <br /> MINIMUM 24 HOUR ICE NOTICE REQUIRED FOR(INSPECTIONS-PLEASE CALL(2091953-7697 41 <br /> SIGNED -�--�_ ` -.Y��1� RTL" C'� ��-+�` DATE <br /> I <br /> C <br /> ENV( WTI <br /> ' IIVED <br /> r - - <br /> 2016 <br /> COUNTY <br /> ENTAL <br /> y <br /> PA T M E N T 4SE q IN L Y HEALTH DEPARTMENT <br /> Applicabon A=epted Date v Area Employee(DO <br /> Grout Inspection By Date l _ C SPECIAL Well Permit <br /> Pimp Inspeciion By Dale C' WAIVER Recei•:'ed <br /> Sol Boring Inspection By. Dale Constructed Weil Depth ft <br /> E BL/' /y�5✓1y4 � �ZiT <br /> PE SC Received CheclM I Arnotmt ate Permit/ Invoice# We9ID# <br /> Codes Into B Cash ReinMed Service Request# <br /> 8 1 / "' � 2'I�II, 015122 lP 3 <br /> WELL/PUMP PERIAr <br /> Received Time Juin, 16. 2016 10: 36AM No. 0900 9776 <br />