Laserfiche WebLink
rs � <br /> WELLIPUMP PERMIT <br /> SAN JOAOUIN COUNTY ENVIRONMENTAL HEAT.Tit DEPARTi.It IIT 1868 EA;i HALELTON AVENUE-STOCK TOPI CA 95205-6232(209)4603420 <br /> NON-REFUNDABLE PERMIT <br /> ___/_ y��Www-2,192 .or�l/e� d __ ,E/X�PPI`R'ES 1 YEAR FROM DATE ISSUED <br /> Jon ADDRESS rL J[J CE/.��� l'S�y���f,7 e �.O�jV,ILI CITYIZIP _FyAo-1 <br /> !Nam J <br /> CROSS STREETp YA1R UrW `PARCEL SIZE AND USE <br /> �APPLICATION <br /> ,NI <br /> OWNERNAME r♦� ` 1— 1 r I •�1 l+�`v�l PHONE✓'J�/ �/��1 �+ r�y N' <br /> OWNER ADOREss W0 17o a CITYISTATE/ZIP rnerctd ►cp q63" <br /> CONTRACTOR G11%GV-Imn� e�,�D61111 M I • ��w �P/N�ONE/�,J5L I�`�,/+�5.2- -22 e <br /> CONTRACTOR ADDRESS 1555 N M c Ca11 F" f nL)L CITY/STATE/ZIP `J✓1ngR/r1 `- o 1 7Wis-1 <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CIITTYISTATE/ZIP <br /> LICENSE XC-57 C C-61 i D-09 L;Ulher NUNIDER66 LIX6 EXPIRATION DATE ai LLJL� <br /> BILLING PARTY: Li OWNER CONTRACTOR SUBCONTRACTORICONSULTANT <br /> DOMESTIC WELL SAMPLING:"i General Mineral/Coliform Bacteria(4391)_: Dibromochloropropane(4392)" Arsenic(4393) <br /> INTENDED USE OomesliUPrivale Irrigalion/Agricullural L Industrial Water Quality Monitoring Soil Sampling/Characterization <br /> -. Public Water System <br /> Il different 1r 0-, MI.,System Name Conlecl Name er PI... NwnU-r <br /> TYPE OF WORK ew Well Replacement Well WeII Alteration/ModiGcalion _Other <br /> Monitoring Well(s) B of Wells Soil Boring(s) c of b-nvs Geotechnical tl oI ba"'ei <br /> Out Of-Service Well Out-Of-Service Well Renewal ,,Cross-Connecllon Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> WELL CONSTRUCTION n �n �Vl <br /> Drilling Method Mud Rotary. .: Air Rotary C Auger Cable Tuol . Push Point X OlherK_ GVG q-C a.c o ! <br /> Proposed Well Depth q'10 II Excavation in diameter J Open Bottom Gravel Peck/Gravel Size in diameter <br /> G Conductor Casing In diameter / Cond clot Casing Depth it <br /> Well Casing Diameter In Thickness/Gauge/ASTM Schad WE ❑Steel 9Plasl1c _Stair'---Steel :i Other <br /> Grout Seal Depth 2 DO It _.Neat Cement(94 lb bag/5.10 gal water) Sand Cemenl_J04�SP•t G sack mix/7 gal water <br /> Bentonite(20%solids) .-:Other <br /> Grout Placement Method KPumped L Free Fell G Other C Retardant/Accelerator(name) <br /> PEDESTAL Installed By j Driller j Pump Contractor ij Other <br /> I i Concrete Pedestal I(Dimensions:Width_It Length It Thick In I Christy Box I Stove Pipe <br /> PUNP D Submersible❑Turbine 3 Other HP Pump Sel It Standing Water Level R <br /> I 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. 1 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- 4.8 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)95 7697 <br /> SIGNED V TITLE SuRo n Kr,dAr- a <br /> nt- DATE (% l0 2W <br /> O <br /> USN <br /> pgRT OO <br /> L—dtiry <br /> r�FA( <br /> DEPARTMENT USE ONLY <br /> T / <br /> Application Accepted By�.1� LCL Dale 7 J-'t Area a << Employee IDB S� <br /> Grout Inspection By -i-Y L - Date e;�-;'," SPECIAL Well Permit <br /> Pump Inspection By Date L: WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth h <br /> COMMENTS <br /> PE Sc Received Check/( AmGun l Date Permit/ Involve a Well IDA <br /> Codes Info c s Remitted Service Request A <br /> L 6 C) <br /> I <br /> END 410o 611 112019 - � WELL/PUMP PERNR - <br /> t <br />