Laserfiche WebLink
WELUPUMP PERMIT <br />SAN JOAotrai ColarTY EwRONNERTAL HEALTH DEPARTMENT 600 EAST MAIN STREET - STUMTON CA 95202 - 1209) shes420 <br />NON-REFUNDABLE PERMIT CALL (209) 953-7697 FOR INS_ PEONS EXPIRES 1 YEAR FROIm DATE ISSUED <br />JOB ADDREBa �� K/ <br />_ CrtrlLP y J <br />A <br />.O <br />CRDaS STRI.-FT APH �/20-:32PARCEL SiE:3 -'-J�r LAND USE APPLICATON A_ <br />OWNER NAME/% a,)�j�� <br />OWNER ADDRESS I / 1(� NEIL YI$TATE/Z10 . <br />CowntACToit PNOe1E A <br />:TOR ADDRESe <br />I- (_57 L (.-61 C D-09 <br />Ci7vf5TATYJZIP <br />PHOW <br />_ CnYISTATEMP__ <br />NUMBER ExPtRAT10N <br />GEOORARUCAL INFORMATION: Coordinates X Y Township _ Range Section <br />INTENDED USE omew`P-vafa C IrngabonlAgriallaral lx <br />❑ Irldualrlal ] Water Ouallty Mldoring I SOMI Sarrlp ,ct <br />Charaenzatlon <br />- - Pubxfllic Water SYstem -- - -- ` <br />Ir cflterarrl tom 0— VWDI 5W.M Nii— a r <br />TYPE OF WORK I New wen .. Replacement We@ ' Well AherationiModificalmn i ane+ <br />D Monitoring Well(s) t or wags C Soil Boring($] a 0 WKVW I Geofeclnirsl s ec bo -,r <br />?(Out -0f -Service Well I Out-Of-Servlce Wed Renewal C Cmsa-Connecion Repair <br />f 1 New Puna -1 Pruni R—Wnemnd r' Rum Rerwlr i Rai" VVPII f oivr <br />ELLCONSTRUCT IN <br />111ing Method ❑ Mud Rotary 7 Air Rotary Ij Auget I Cable Tod Pwrh Pant 17 Other <br />oposed Well Depth tt Excovadon In diameter ! I Open Botlom I I Gravel PadJGravel Sue in diameter l <br />Il Conductor Casing in dlanwter I Conductor Casing Depth ft i <br />Well Casing Diameter _ in Thicknes&'Geuge/ASTM Scheel 7 Steel t' Plastic I Stalnkss Steel I I Other <br />Grout Seel Depth ft 11 Nkat Cement (94 /b beg15-10 pa! valor) n Sand Cement sack mI.J7 gel water <br />Bentontfe (20% sodds) -1 Other <br />rout Placement Method Purrped 1 Free Fag Other LI Retardant I Accahnelor fnerne) 7 <br />PEDESTAL Installod By !.I Driller U Pump Contractor 7 Other <br />. - U Concrete Pedestal Dimensions: Width ,ft Length _---- ft Thick In L Christy Box --' Stene Plps <br />�uMP D Subrimsible- Turbine D Other HP Pump Set R Starling Water Level t <br />I HEREBY CERTIFY THAT 1 RAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />,DAWN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE M <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE HOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />DEPARTMENT USE NLY L c/ <br />Application Accepted By Date a_1__ i -BeEmployee IDS <br />Grout Inspection By Date 14PECIe11 PenTitt <br />Pump Inspection B Dalo�= WAIVER Retelved <br />Soil Boring Inspection By Dale Constructed Wall Dppthth ft - <br />COMMENTS K 1% I)o C D4� <br />PE SC Received Amount — Penn1U <br />Codes Into Cash Remitted Date Service R nest R Invoice • WellIDN <br />o <br />E4D 4100 - �� VrT Iv PUMP PEiMr <br />aosroa <br />L <br />