Laserfiche WebLink
WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARramr ISS EMT Hamm AVENUE-STocRroN CA 95209.8232(209)4683420 <br /> NON-REFUNDABLE PERMIT W Ww•Gligair EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB <br /> ADDRESS , �_i•44.�ey-.c?l.",""/-F Q.. ` CRYlZIP �� i�'/1 7�r p <br /> CROSS S.f. e! G.rC Cj/�j AP.N�. 17 O T I PARCEL.SI2E LAND USE APP/La/�c77rArw/rr/q/ A ,q <br /> OWNER NAME (�[i/DI•II'y� ft <br /> ,�,�`�0'v a�e�`VOQ <br /> OWNER ADDRESS a / / CT'/STA7Ef2aP�p /1/. — �DC <br /> CONrRAcrnR /�RyC. 14) s''7t?�ZQi7 ext. Z <br /> I <br /> CONTRACTOR AODRESBAVe J� �'^ ! • /T N'_7�ISTATEZIPSNG,-- <br /> SUSCONTRACTORICONSULTANT 6 ro~FA PI7• /�,PHONE ,�� <br /> SUSCONTRACTOWCONSULTANTADDRESS /D n� c-wsTATE/ZtPA xa,,ACAy?T6 2aJ <br /> LICENSE r-C,67 C C-61 a D-W D Other NUMSER2SIM 7 EviRATroNDATis /�3I/ZOLO <br /> IBILLINGPARTY: DOWNER ❑CONTRACTOR 016111CONTRACiOWCONSULTAN7 <br /> DOMEsT h:WELL SAMPuNo:G General Mlneral/COlNorm Bacteria(4391)0 Dibromochioropropane(4392)0 Arsenic(4393) <br /> INTENDED WE 0 DomeaUc/Private D hrigatlontAgriceiturai C Industrial O Water QueCdy Monitoring WISoll SamplinglCheracterization <br /> o Public Water System _, <br /> If dV1..l ham O—r.. Weror Syefam Name _ Cprl4q Nrane a Phone Nwnher <br /> -A <br /> TYPE OF WORK C New Wall 0 Replacement Well C Well AllorMoNModHicetion 0 Other <br /> 0 Monitoring Won($) #otwells 0 Soll Soring(s) tlofbarbrpe GtoGeotechnicai_ r._r�601115' <br /> C Out-OlServke Well 0 Out-O/-Service Well Renewal C Cross-COnnection Repair <br /> 0 Naw Pump 0 Pump Reptacem�anf 0 Pump Repair 0 Raise Well Casing <br /> MMLLMAIRIMMM <br /> Drilling Method Mud Rotary 0 Air Rotary LX AuOar 0 Cable Tod 0 Push Paint ❑ Other <br /> Proposed Well Depth/—Jr-s,R Excavation y 4' In diameter 0 Open Bottom 0 Gravel Pack/Gravel Stze in djmne4w <br /> C Conductor Casing in dlameter / Conductor Casing Depth— R <br /> Well Casing Diameter in Thickness/Gauge/ASTM Schad 0 Steel 0 Plastic C Stainless Steel 0 Other <br /> Grout Seal Depth/�_it Xaad Cement 04 lb bag/Si0 gat water) 0 Sand Cement sack n7ix17 g <br /> 0 Bentonite(y%solids)/❑Other <br /> LI-rout PlacementMetho< Pum d 7fre Fall 0Other 0 Retardant/Accelerator(neme <br /> I FEW-131ft Installed By 0 Drill 0 Pump ContractC Other <br /> 0 CotLorah PedestalODitmnatons:Wkith or R LZ...h It Thick In ❑Christy Bo= ❑Stow Pipe <br /> `PUMP 0 Submerstele0 Turbine 0 Other HP Pump Sel ft Stentlirg Water Level R <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 /> MINIMUM 48 HQU$6D <br /> NOTICE REQUIRED FOR INS TIONS-PLEASE CALL(209)953-776697/ ,^ Q <br /> SIGN®__ <br /> fill IIIIIII <br /> fill 11111111 <br /> /wIA14 <br /> i <br /> 'AUG ®6 F® <br /> I ✓Ro USN co OjS� <br /> Ty <br /> EP TM ENT�U E NLY <br /> Application Accepted By ate Aroae Employee P Yee 1D# <br /> Grout Inspection By Date _ - 11 PECIAL Well Permit <br /> Pump Inspection By_ Date 0 WAIVER Received <br /> Soil Boring Inspection By loaf 9 Constructed Well Depth ft <br /> COMMENTS <br /> PE SC ltecdved Checlf Amourd -- — <br /> Codos Into m B da Ssrvlas = 6te'al.0 1 Wall IDN <br /> If NPM-3e;1;14 <br /> EHD434e e141=11 _ we.LavatPPeaar <br />