Laserfiche WebLink
���a��" ��� rP,G.u��� lj���'��2- � I D 15�2�Z� a-�h�• C-�lr�u�' <br /> �,n�a<« dse <br /> WELUPUMP PERMIT J gra <br /> SAN JOAOUN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZE LTON AVENUE-STOCI T N t.A�9S � 3 ZU �9LU <br /> NON- F DA LE PERMIT wvvvv.claov.or lehd EXPIRES 1 YEAR FROM DATE ISSUED <br /> If <br /> Joe RESS CmIZIP f ;a <br /> 1 D <br /> CROSS STREET Ay �( /'1/-'- PARCE SI E 9E T N iF <br /> OWNER <br /> Cau�/ 1 <br /> OWNER ADDRESS 1 I I r(t r Z l+m CrTY/STATEILP <br /> CONTRACTOR ^'�J I ti�ln P <br /> CONTRACTOR ADDRESS ✓ C TY/STATEMP I <br /> SUBCONTRACTOR/CONSULTANT <br /> SUBCONTRACTORICONSULTANTADDRESS VfSt �+ TEILP / VV <br /> LICENSE LC/:/57 C-61 609 Other NUMBER -* �3 h EXPIRATION D TE 'J <br /> BILUNO PARTY: (OWNER CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: General Mineral/Coliform Bacteria(4391),Dibromochloropropane(4392) Arsenic(4393) <br /> INTENDED USE DomesliclPrivale Iniga6on/Agrcu tuml Industgal Water Quality Monitoring V Soil Sampling/Charactenzation <br /> Public Water System <br /> It different ham Owner Waley S"*rn Name Contact Name or Phone Number A <br /> TYPE OF WORIti::New Well IReplacement Well .Well AlterationlModcation 'Other ^)Y <br /> O Monitoring Well(s) #of vials Soil Boring(s) a°r borings Geotechnical M or borings <br /> Out-0f-Service Well Out-Of-Service Well Renewal Cross-Connection Repair ` r/ <br /> Nnw Pump -Pump Replacement ..Pump Repair Raise Wen Casing <br /> �WELLCONSTRUCTION U / <br /> Drilling Method Mud ary Air Rotary IJAuger Cable Tool Push Point Other <br /> ProposedWell Depth {ft -xcavation in diameter Open B !Gravel Pack/Gravel Size in diameter ✓Oq 2020 <br /> con <br /> du r Casing in diameter ! Conductor Casing Depth it HE r IKON COO <br /> Well Casing(�r <br /> ter m; sickness! augelASTM Schad Steel Plastic Stainless Steel other Grout Seal ✓ fI eat Cement(941b bag/r10 gat Water} Sand Cement sack mrWl gal water Bento ate(20 sa(ida) G Other nlT <br /> Grout Placement Method Pumrped ;,Frae Fop Other dant/Accelerator(name) <br /> PEoesTAL Installed By OnMOt <br /> er r,Pump Contractor her <br /> o1 <br /> Cncrete Pedestal .Dimensions Wdth P. Length it Thick in Christy Box Stove Pipe <br /> PuMP _Submersible,�Turbine a Other HP Pump Set ft Standing Water Level ft <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, 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(.AWS. <br /> MINIM 4 OU AD ANC OT CE REQUIRED FqR INS PEC NS PLEA CALL(209)95 -76 r <br /> SIGNED TITLE DATE <br /> i <br /> I <br /> I <br /> It <br /> I <br /> DEPARTMENT USE ONLY <br /> Application Accepted By l=ip �f��- Date J S Jr,r4- /Vlm �'f`%'r+2� Employee ID# i),� <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By /� Date WAIVER Received <br /> Soil Boring Inspection By�h.t•S L7 &At- lG"k.M Date I G12,117, l_- Constructed Well Depth It <br /> COMMENTS <br /> PE SC Received Chaatd! Amount Date PermW Invoice# Well ID# <br /> Codes Info Remitted Service Re uest# <br /> 7a� 3!36g <br /> EHOuoe e1f1101a �— —' y IWELL NUMr'aEqMR <br />