Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JIOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 EAST MAIN STREET-SrocicroN CA 95202-(209)468.3420 <br /> NOWREFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> u <br /> Joe lu DRE88I-L_ t >�A1T[�CZ �L�}R CITr21P LSCA_ ( �' Al - <br /> CROSS STREET SQWft RW J tI r <br /> l 1�1N1 W APN_1-!_j.-_I h 0-'f-f PARCEL SIZE•LAND USE APPLICATION# <br /> OWNER NAME PHONE <br /> OWNER ADDRESS CITYISTATILZIP <br /> .1 r <br /> CONTRACTOR P aIAAL 1'J._ kfJ-� S0 N A �tF <br /> _�S OC4 S PHONE 2D9 <br /> CONTRACTOR ADDRESS -1 aZ C.ISTATEMIP L.O t)I <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS- CITY/STATEOP <br /> LICENSE >,G57 ❑"1 C 0-09 1 OtherNUMBER OD EXPIRATION DATE T <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section m <br /> INTENDED USE 0 Domestic/Private 0 Inigation/Agricultural C Industrial 0 Water Quality Monitoring Soil Sampiing/Charactarization ll 1 <br /> J Public Water System <br /> fN dL%t&t fmm Owner walerzymm NO" — -----l7&%iZl1Wn—wur r <br /> TYPE OF WORK 7 New Well C Replaxment Well n Wet AlterationlModlfcation J Other <br /> Monitoring Weils #of wells C Soil Bori a of borings •"rin's <br /> ( ) ng(s) Geotechnical�_ <br /> ;1 DUt-Of-Service well ❑Out-Of-Service Well Renewal ❑Cross-Connection Repair <br /> 0 New Pump J Pump Replacement 0 Pump Repair <br /> WELL CONSTRUCTION <br /> Drilling Method n MW Rotary n Air Rotary .Auger J Cable Tool J Push Point ❑ Other <br /> Proposed Well Depth 1_ft Excavation4 in diameter ❑Open Bottom n Gravel Pack/Gravel Size in diameter <br /> I Conductor Casing in diameL.r I Conductor Casing Depth ft <br /> Wall Casing Diameter_in Thickness/Gauga/ASTM Schad n Steel C Plastic J Stainless Steel C'Other <br /> Grout Seal Depth ft ❑Neat Cement(941b bag/5-10 got water) '. `i.7 Sand Cement sackn?&17 gal water <br /> Bentonite(20%solids) Other Seta, (,t 772AlAs . WaLG PL-JAit ZF <br /> Grout Placement Method C Pumped 'Free Fall ❑Other_ _ G Retardant/Accelerator(name) _ <br /> PEDE818L Installed By ❑Drliler ❑Pump Contractor LIQ er <br /> J Concrete Pedestal Dimensions:Width ft gth— <br /> ft Thick in 7 Christy Bos ❑Stove Pipe <br /> EUIIII_P C SubmersibleC Turbine ❑Other 9 Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPI ICATI0161 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 T14E CALIFORNIA CONTRACTORS STATE LICENSE 130ARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> BKiiIED /Wf�l-v+�� i7TLE If A-3LI ECT ENX�I/VE, 'K— DATE- <br /> 0. <br /> ATE <br /> �..{-IIT-F4 <br /> J 10.110 <br /> M, <br /> JjEQ Ll <br /> ?:r•o'" <br /> w <br /> .o 3, r N Ir"5P' W 169.Kr I-:aci✓.."!-u�``"^J'^'�^'-".... C <br /> D <br /> DEP RT ENT U E ONLY <br /> Application Accepted H )IYGUII S l ate Area Empblree ID# My <br /> Grout InspectJon By Date J SPECIAL Well Permit <br /> Pump Inspection B Date 0 WArvEiR Received <br /> Sot Boring Inspection Date Constructed Well Depth ft <br /> COMMENTS <br /> ^PE SC Received Amount Permit? <br /> Codes Into B Cash Remitted DoteeSev Invoice# Well 1100 <br /> sD 83 {S `'" a S' s <br /> EHD 43.09 WELL(PUMP PERMIT <br /> IirzISN7 <br />