Laserfiche WebLink
R WELUPUMP PERMIT <br /> SAN JOAQM Cou ff EulnRat111111811TAL HEALTH Dff%RTMBTT 1868 EAST HA>S um Ave"-SToclam CA 95205-(209),168-3120 <br /> NON-REFuNnAB F Pyr CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> Joe Atmos vsi G�-• 3 f.� '7 o,Yae <br /> CROS. M <br /> CROS7. Ol S APN l7l r 0J st PHONE Patin S= LANo usE APraxanoN f o <br /> i'Y1 Z"T 8�z��s3�o <br /> OwNNAtrE _ _-- a <br /> Owum AnOttEss S e _ CTTYMTATE/Z)P <br /> CONTRACTOR /�/41-i� Py. z�,`/ /�� <br /> CONTRACTOR ADDRESS 8osy �/a'1'1'e_ /Gd - Cm'IS�A.111- OAot.� 1_ elf" 7561 <br /> SUBCONTRACTOR PHONE <br /> SuscatrTRACTOR Anmmss CT Yl5 ATrJZ F [� 7 <br /> l lmisE ❑G57 lit ❑D-09 L Other Nu t q�7Z $ E..D. <br /> DI»WELL ❑General MsleraUCofdorm Bacteria(4391)G Dibromochioropropane(4392)❑Arsenic(4393) <br /> r�2�i <br /> lm❑ patir ntAgrinlha &ral 0 ln17ial ❑LNhter OuaHY Mandorin0 C Sia❑Public Wale System <br /> e mat tro.e Owoor. VVA.s1�_Name Cudad Name a Pt—i M-b- <br /> TYPE OF WORK ❑New Well 0 FZtplaccrncrt Well ❑Well AfterafionJ6bdillirabon 0 Omer <br /> ❑Monitoring Wows) s of weds ❑Sod Bonng(S) •,I!,*'_ U Geotledvtiral <br /> - Wed ❑Out-O(-Setvit:e Well Renewal ❑Cross-Connection Repair <br /> ew R ❑Pump Repair ❑Rye Wed Casing <br /> W0_L CONsTRucTTOrt <br /> Dn4oty Method ❑Mud Rotary C Air Rotary 0 Auger C Cable Tool ❑Push Point ❑ Other <br /> Proposed Well Depthft Excavation in darneter D Open Bottom ❑Gravel PadUGtavel Size in dameler <br /> G Conduct"Casing m diameter / Conductor Casing Depth ft <br /> Well Casing Dreenda in Thicknesgr3atgedASTM Silted 0 Steel 0 Plastic 0 Stainless Sleet U Other <br /> Grout Seal Depth_ft n Neat Cement(94/b bag/S-10 gal wated 0 Sand Cement sack moll gal water <br /> ❑Berdonfie,(20%Solids) ❑Oftner <br /> Grout Placement Medved ❑Pumped ❑Free Fad -_Other Retardant l Accelerator(nave) <br /> PEOESiAL hlsmlled By ❑Drier ❑Ptmtp Contractor ❑ OOler <br /> ❑ trete Pedestal❑Dbnranions:Width R Length ft Thick m ❑Christy Bo= ❑Stove Pipe <br /> fTetsal>fe0 TlaDne C OCter HP Po^P R Stands g Wats Level R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE W ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDIMANCES.STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT YY REt]IIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS <br /> PIA• MA 4S H UR ADVANCE NO i iCE REQUIRED FOR INSPECTI MNS-PLEASE CALL(209)953.7697�j <br /> Stt�® TntE /L fi DATE <br /> �r <br /> 5 <br /> qQ 200 <br /> / DEPARTMENT fpUS. ONLY Q �Fpq�A1t��NT� <br /> Application Accepted BY �" ! Date S'V/,�; 0 0c Area EmploYeo It)Q •' •r/�.A✓T <br /> Grout Inspection By Date_ ❑ SPECIAL Well Permit G <br /> Pump Inspection By i.vtu S c ( ( n L 't- Date `(�( 10 I iG ❑ WAIVER Reoetwed <br /> Soil Bang Inspection By Date Constructed Welt Depth R <br /> COMMENTS <br /> PE SC RecaLved Checkff Amount �� Permw by�o S WeY IDC <br /> Codes heti Remdh!d ice RequestS <br /> eloa-es ia.tveoaTane waL�t>�r�wtTT <br />