Laserfiche WebLink
► ; /Orr;' _ %/:Ole <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELToN AvENuE-STOCK70N CA 95205-(209)468-3420 <br /> NON-REFUNDABLE[PERMIT CALL 209 953-7897 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE IssuED <br /> IJOBADORrss !-i Is(� E . A c.c:,;" i=�C, I`% f CITYIZIP <br /> CROSS STREET�� -�' n I-N - ,c �. 1 DAPNQ�7�iZO-V 3 PARCEL SIZE/. <br /> _ _- LAND USE AppucAT"0 <br /> OWNER NAME <br /> r—r—�Lv 4 t PHONE „J�, r 1{C._ '•S-1�-,,�" r� <br /> OWNER ADDRESS 1 f /; .'`L 1;� , I j Y i -` r' { j <br /> O CITY/STATE/LP_ l'�"{ t �J C-t c) <br /> CONTRACTOR �, � �T `( I� I i,-f PHONE _:�S - �-7 -7c1 <br /> CONTRACTOR ADDRESS r' r ,7 CrryfSTATEIZIP i - - <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATEIZIP <br /> IUCENSE k C-57 V C-bt D-09 Other NUMBER ExpfaAnoN DATE <br /> GEOGRAPHICAL INFORMA TION: Coordinates Y Township_ Range Section_ <br /> INTENDED M X.DomesbclPrhrate Imgation/Agricultural - Industnai Water Quality Monitoring Soil Sampling/Characterization <br /> Public Water System <br /> 1 dMr�nt from Owner. Y.— a �or na u <br /> TYPE Or WORK ):,New Well -; Replacement Well Well Alteration/Modification Other <br /> Monitoring Wefl(s) ti:of wells Soil Baring(s) t:or bonngs Geotechnical a or bonngs <br /> Out-Of-Service Weil Out-Cf-Service WeI Renewal _ Cross-Connection Repair <br /> XNew Pump Pump R lacernent :. Pump Repair Raise Well - sin <br /> W ElL CONSTRUCTSON <br /> Drilling Method'(Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br /> Proposed Well Depth 3 iLf C, ft Excavation i -,1 in diameter Open Bottom Gravel Pad1/Gravel Size %t� in diameter <br /> Conduct Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter in Thickness/Gauge/ASTM Sched C l,,'L+ Steel f Steel Plastic Stainless Steel Other <br /> Grout Seal Depth ,l; , ft Neat Cement 194 Ib 10 gal waleq ',,,(Sand Cement ', sack nx17 gal water <br /> Bentonite(20%solids) Omer <br /> Grout Placement Method Pumped - Free Fam Other Retardant/Accelerator(name) <br /> PTOEsnstalled By >,DriuerPumWip Contractor Otner <br /> Controls Pedestal,Dimensions dth� It Length R Thick ! in Christy Box Stove Pipe <br /> ,PUMPSubmerslble Turbine Other HP Pump Set 5 It Standing Water Level ,-r ft <br /> 1 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. <br /> MINU 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7897 <br /> S$GNED '� .' r (:,� +ZCt� TITLE C( , L <br /> t��e C . (1 f Yi T DATE I <br /> FF <br /> 1 ` l <br /> I 1 I i I <br /> 1 <br /> K <br /> / I <br /> 3 p <br /> i <br /> 1 1i <br /> r <br /> AR MENT SE ONLY <br /> Application opted ate Area Employee ID# J <br /> Grout Inspection SPECIAL Well Perrntt <br /> Pump Inspection By w Data ' WAIVER Received <br /> Soil Boring Inspection By Date Constructed Wall Depth tt <br /> CgMMENTS r LIE— L <br /> _ A2&1 <br /> r - j L <br /> IPE SC Received Ch Info Ca Refmlttedt Data Service eRequest s Invoices Wall IDs <br />