Laserfiche WebLink
PHONE SUBCONTRACTOR/CONSULTANT <br />dCONTRACTOR 3 SUBCONTRACTOR/CONSULTANT <br />SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br />LICENSE X C-57 P C-61 n D-09 7 Other NUMBER LIC;7 S".7 EXPIRATION DATE IR/3 <br />BILLING PARTY: C OWNER <br />501 We-sl- ta e,hor /Inn ve, <br />041-erfv-on-i- Oce Towfis OvsJne-r 1-2-17., PHONE <br />OWNER ADDRESS po y a 3 1.4; CITY/STATE/ZIPv/STATE/Zip kiD 31 7., <br />CONTRACTOR Kit i p... z,o.0 9 14 3 <br />Avoarq- goe s4e- 'CITY/STATE/ZIP 54-0c, tb*I itg CONTRACTOR ADDRESS 7190 / /:WCA <br />Ciry/Zip <br />NON-REFUNDABLE PERMIT www.sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br /><5'vc-ktoPt 95 z,o3 JOB ADDRESS <br />CROSS STREET 5 • 1, col", APN 13174 03s' PARCEL SIZE 3. 2LLAND USE APPLICATION # <br />OWNER NAME <br />CGrout Placement Method Pumped Free Fall 7 Other -I Retardant/ Accelerator (name) <br />ft Thick In 0 Christy Box 0 Stove Pipe <br />PEDESTAL Installed By 0 Driller C Pump Contractor D Other <br />D Concrete Pedestal DDImenslons: Width ft Length <br />ft Pump Set ft Standing Water Level HP PUMP D Submersible :I Turbine D Other <br />WELL CONSTRUCTION <br />Drilling Method 11 Mud Rotary 0 Air Rotary E Auger 0 Cable Tool 7 Push Point d Other thAld liblie-r- <br /> <br />Proposed Well Depth 5-)0 ft Excavation In diameter C Open Bottom E Gravel Pack/Gravel Size in diameter <br /> <br />-1 Conductor Casing In diameter / Conductor Casing Depth ft <br />Well Casing Diameter In ThIckness/Gauge/ASTM Sched C Steel : Plastic C Stainless Steel 0 Other <br />Grout Seal Depth '-' lb ft 4 Neat Cement (94 lb bag/5-10 gal water) C Sand Cement sack mix/7 gal water <br />I Bentonite (20% solids n Other <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 LAWS. <br />SIGNED 6144—. <br />MINIMUM 48 HQUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />TITLE 1-01,1-e illy nu-4-- DATE •ps <br />hed <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE - S-rocx-rcui CA 95205-6232 (209) 468-3420 <br />DOMESTIC WELL SAMPLING: C General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE 7 Domestic/Private 0 Inigation/Agricultural C Industrial 0 Water Quality Monitoring Soil Sampling/Characterization <br />Public Water System <br />If different from Owner Water System Name Contact Name or Phone Number <br />TYPE OF WORK I New Well <br />I I Replacement Well I Well Alteration/Modification Ii Other <br />-I Monitoring Well(s) # of wells F Soil Boring(s) 8 °f borings 11 Geotechnical <br /> 5 <br /> <br /># of borings <br />_I Out-Of-Service Well L Out-Of-Service Well Renewal Li Cross-Connection Repair <br />] New Puma D Pump Replacement 0 Pump Repair 0 Raise Well Casino <br />DEPARTMENT USE,ONLY <br /> <br />Application Accepted By 7Z1V- Date <br /> <br />Grout Inspection By Date <br /> <br />Date <br /> Date 6/1 11/1 <br />Pump Inspection By <br />Soil Boring Inspection By <br />COMMENTS <br />Area 1/stb4k-lon Employee ID# ins <br />SPECIAL Well Permit <br />-I WAIVER Received <br />Constructed Well Depth ft <br />PE <br />Codes <br />SC <br />Info <br />Received <br />B <br />Check#/ <br />Cash <br />Amount <br />Remitted i Permit/ <br />Service Request # Invoice # Well ID# <br />li ra i S- b <br />utiiii. <br />V /5 A .f 1 04,9 <br />Fe <br />9 11)1 VIKOLO-110 <br />12SMS2 12LQ,c1s12 WELL /PUMP PERMIT EHD 43-06 6/11/2019