Laserfiche WebLink
t� Iz3o WELL/PUMP PERAUT <br /> SAN$*AODIN COUNTY ENVIRONMENTAL' TH DEPARTMENT 304 E WEBER AVE -SrOCKTON CA 95202 -(209)460-3420 <br /> NON-REPUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EX!...j&S I YEAR FROM DATE ISSUED <br /> r109 ADDRE68 . .f Yrd20�w li __ r CITVIZIP <br /> CAOSSSTREET !s_rl!LZfCbt 1J�fI� t�.(1T N11 '+d.�PN "� PAACELSIZE�]I tl <br /> OWNER NAME rsL4'liL{� ,S-/;�LIP�LQ- -- - PHONE �Q ' <br /> 1 C <br /> OWNER ADDRESS '7 / Q CITYISTATEMP zoo Ag <br /> CONIRAC't'QEi 1 t. tt PHONE <br /> J CONTRACTOR ADDRESS IL.P,5c lu CITVISTATPIZIP <br /> SUBCONTRACTOR PRONE <br /> SUBCONTRACTOR ADDRESS CITYISfATEIZIP <br /> LICENSE 4-57 Cl C-61 0 D-U9 0 Other N....jjff E---T10N DATE <br /> Fj <br /> GEOGRAPIRI INFORMATION! Coardlnates X Y Township Resign ScOlo0 INTENDED US8 otttestic1Mvatc ❑IrripflordAgriculumt] O Industrial C1 Water Quality Moniloring 0 Soil Sampling(Characted2ation O Public Water 5yy&etem I <br /> Irdirr%M.1.Owner. Vister Symern Name nraet moor no - <br /> TYPtOR WORKeW Well 0 Replacement Well 0 Wel]AlleralionlMadification d Test Hole 0 Other <br /> F,! O Monitoring We1I(s) " eeor-11. O Soil Baring(s) 0 GeotechnicalCI well Destruction EI Out-ORsetvice Well ❑Out-Or-Service Well Renewat <br /> 13 New Pump 0 Pump R lacemem O Pump Rcpsar 0 Crass-Connection&eElr <br /> VIELLCONSTRUCTI N <br /> Drilling Mothod fud clary O Air Rotary O Auger 13 Cable Tool 0 Push Point 0 011ier <br /> Proposed Well Depth ft Excavation^/2 in diameter 0 Open Bouom ^Cravcl Pack/Gravel Size in diameter <br /> I <br /> O COnducnar Casing in diameter I Cooducmr Casing Depth R I <br /> Well Casing Diameter in ThicknodGaugdASTM Sched if�� C1 Steel plastic 13 stainless Steel 00ther <br /> Grout Seal D Ih it Cl Neat Cement(941h lxrb 15-fog.1 nnt,) 0 Sand Cement ruck raiz I?gal water <br /> 8emonias(20%solids) O Mana(seturor Spec%solids % Name 0 Specs on Pile CiSpees Submitted <br /> Gmut Placement Method naed 13 Free Fall 0 Oti:er 0 Retardant I Accelerator(name) <br /> ' PEDESTAL Installed By 0 Driller 04--mp Contractor 0 O:her <br /> Cl Concrete Pedestal Dimensions: Width__ft Length ft Thick in 0 Christy Box 13 Slave Pipe <br /> PUMP O Submersible O Turbine Q Other HP PumpSet R Standing Water Level it <br /> WELLDESTRucrioN 0Open Bottom 0Gravel Park ©Uncased 0011er <br /> Wel]Diameters Total Depth It Depth to Water ti to Casing to be Perforated from fl to ft <br /> Sealing Material 11 Neat Cement(941h hag/S-)Ogrr!Wl1dr) 13 Send Cement sack mix 17 gel water 0 Bentonite Pellets <br /> E3 Bentonite(200A solids) D Manufaeturer Spec U solids °Y Name 0 Specs an Fite 0 Specs Submitted <br /> Placement Method 0 Pumped 0 Flee Fall O Other <br /> O Gamplete with Mushroom Cap 11 below grade 0 Complete to Eyistino Surface Pad <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQU[N COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS 1 ALSO CERTIFYTHAT MY REQUIRED LICENSE t5 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS, � <br /> MINIMUM�2�4�jIRHO R ADVANCE NOTICE EQUD FOR INSPECTIONS JI <br /> SIGNCD { lc{r A. YAW TITLELt.- DATEIV V0 <br /> Fj'i <br /> N ' <br /> -10 011A I I <br /> N <br /> EPARTMENT U NL <br /> Application Accepted By ig4,i2i� Date /11702 Arca 21 1 Employee ID#,, <br /> Grout Inspecpor, — Dere Q © SPECIAL Well Permit <br /> Pump Inspection By Date E3 WAivCR Received <br /> Destruction Inspection By Date Constructed Well Depth R <br /> COMMENTS f <br /> PE SC Amount Chec Received P <br /> Date <br /> Codes Info Remitted Cash B a loroiwR well IDU <br /> F <br /> �s <br /> EHD43-02.006 S 4 Y lgd MASTER WATER WELL PERM LT <br /> snfz002 <br /> ! �'dC1gD <br />