Laserfiche WebLink
WELL/PUMP PERMIT <br /> x94N JOAQUIN COUNTY ENWRONMENTAL HEALTH DEPARTMENT 3D4 E W EaeR AYE k'PL-StOMTON CA 95M -(209)168-3420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-71597 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> .e S ° (�] <br /> JosAnnRl:55 _ / ? 1 C'rrY/Zlr Yt ld+n7m:'6,�ry <br /> CRow SASN ,!— <br /> TnEST EL ZE hT USE APPLICATFOw 1 <br /> D <br /> OwwCn NAME L �}' PHOnE <br /> OWNEFI ADDRrsa CRY/STATFJZIP <br /> CONTIll r <br /> P[tOrra��G <br /> COIrrnAGTORA➢DRESS f CITYISTATE/ <br /> SUBcomTlRAcroR <br /> — PHONE <br /> SUnCpNTRACMIt A➢➢ReaS Cr"1STAT}Zjr <br /> LICENSE C•37 O C-61 13 D-09 O Other NUMBER ExpruATroN DATE <br /> 1 <br /> GLOGRAPHICALINF➢RMATiow: Ceardtnatn X _ Y Township Range sadion <br /> Uv1'ENDED USE m�tirJPtiveto t7 Inigption/Agricultural O industrial 13 Water Quality MOaitol O Soil Sampling/Chatecteri2ation <br /> O Public Water Syarem <br /> IfdJroem flea)Dwttr: ser neem me red umm <br /> T-".03' ew Well. o REPlaccment Well O ltwM <br /> WellAntim adiftcation 13 Test Hole ❑Other <br /> O Monitoring Wells) fE ofvrelis O Sail BarSteg(s) rerpprinp 0 GSul'burinits. Q, <br /> ❑Wel]Deatntc6on ❑Out-0f--Service Well D Out-OP-service Well Renewal <br /> Q New Pump O PU R lacement 0 P—P R "r O Crosa-Concoction R it <br /> WELL ClN9SfRDCTI <br /> Drilling Method ' Mud Rotary O Air Ratary O Augur O Cable Too] 13 Push Paint O Other <br /> Proposed Well Ilcpth ft Excavation in diameter 0Open Bottom h(Oravel Pack I Gravel Sim in diameter <br /> O Conductor Casing in diuneter / Conductor Casing Depth ft <br /> Well Calling Diameter in ThicknesviGauge/ASTM Sched t&Q O Steel 4#1astic O Stainlps Steet O Other <br /> Grout Seal Depth R O Neat Cement(17116 bag/J-10 gal waver) ❑Setul.Cemenl sac*mix 17 gel water <br /> „bJ°tonne(20%Solids) ❑ManufhMrcr Spec%solids `R Nunn ❑Spon on File ❑Specs Submitted <br /> Grout Placement Method O Pumpod O Free Fall ❑Omer 0 Retardant/Accelraator(name) <br /> PEDPSTAL Installed BY O Drilter ump C-mrtrector ❑Other <br /> 0 Concent Pedestal Dimensions: Width_ft Length R '!hick In ❑Christy Boa ❑Stove Pipe <br /> her <br /> PUMP I7 Submersible O Turbine OOtHP Punrp Srt ' ft Slanding Water Level It <br /> WELL DEBrMUCTION O Open Bottom ❑Gravel Pack O Uncssed ❑Omer <br /> Well Diameter in Total Depth ft Depth to Wooer ft ❑Casing to be I mforstcd from A to R <br /> Sealing Material O Neat Cairene(91 M brg 13-/d gut waver) O Said Crment .rock mix/7 gal water O r3aaCmthe Pillets <br /> Cl Bentonite(20%solids) O Manulactuier Spec%aolids % Name ❑Spscs ca File O Specs Submitred <br /> Placement Method 0 Pumped O Free Fall ❑Other_ <br /> O Complete With Mushroom Cap 11 below gri;. ❑Complete to Existing Surface Pad <br /> I HEREBY CBRTTFV 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 18 <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT i AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> ir MINIMUM HOURADvANCE NOTICEEQirt/R/ED FOR INSPECTIONS <br /> SrGNED C/ TrrLE, ! N DATE <br /> Oi <br /> b. <br /> -15 ALA <br /> 2 <br /> BD <br /> D <br /> 0 - <br /> -1 <br /> AF <br /> L - G <br /> U! <br /> N E <br /> a <br /> EP <br /> •ZSa' 8 f- DEPARTMENT U LY <br /> Appticeeion Accepted BY, Date Area Employee lop _ <br /> Grout Inspection By Dose Il0 0 SMCIAL Well Permit lll�f <br /> Pump Inspectior By Dau O WAIVER Received <br /> Destruction inspcction By Date Constructed Well Depth R - <br /> c ,w''LL <br /> COMMENTS 7 N' M6 `IIrS D - Scfi l Y6 <br /> 141b - <br /> PE St= Received 1 Amount <br /> Codes Iofe B -rash Remitted nue mPermit! g lnvoice0 well IDO <br /> Sece <br /> EH➢4342.-00E <br /> IN2h2te] <br /> MAS1Ee WATER WELL PERMIT <br /> t <br />