Laserfiche WebLink
WELLIPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1888 EAST HAZELTON AVENUE-STOCRTON CA 96205.8232 (209) 488.3420 <br />NON-REFUNDABLE PERMIT www.sjgov.org/ohd <br />EXPIRES 1 YEAR FROM DATE ISSUED <br />15o P� 11 <br />v% PILlyi; <br />953. 7 <br />JOB Aonil ntcxry CRY</ZIt, l71/Wrr[A <br />, <br />77Z v "/l -3z0-S -7 PARCEL SIZED'('LANG USE APPLICATION 14 <br />CROSSSTRECT / Kfi0/�n)SON* OPI rn <br />�yAPN <br />OWNER NAME AA r7N Dy KN&1uP7 _ <br />PHONE <br />OWNER ADDRESS c;e 1 (Df,"so CITY/STATEIZIP <br />q�E` • <br />�J <br />"U 11 r CI t 4 ' C)1 <br />ryA� ,, 1 <br />CONTRACTOR IiIEL'N(.V Loo L:X1tG0AAT)l.v" (/ZUSS) <br />/ <br />g16-S7Q-1Z`/ZD <br />CONTRACTOR AODRESS 107`/7/_ S�vI ,4(S9 14VENV B-33`� CITY/STATE2V <br />%PHONE <br />/�us�✓IL�'E{ C'n L��66 <br />r%irt <br />SuOCONTRACTOWCONSULTANT Gt,yakrr 'I'A/'1 SSLIL) 7��L'ppS, 1/u(,. <br />P...NR Lir11(4" 4.2&- 51�`- <br />SUDCONTRACTORICONSULTANTAODRESS 1oNU( NlLftL'S IJf Nl; CITY/STATFJZ��IP <br />,�J -? <br />m J CA -1-5/lp6 <br />p(P`tx <br />LICENSE n C-57 1 Gel r DOS n Oliver NUMeeRC-57 10391881•XPIRATIONDATE May 31, 2022 <br />BILLING PARTY: - OWNER U CONTRACTOR SU13CONTRACTOR/CONSULTANT <br />DOMESTIC WELL SAMPLING: I I General Mineral/Coliform Bacteria (4391) ❑ Dlhromochloropropane (4392)11 Arsenic (4393) <br />INTENDEDUSE tl Domestic/Privale J Irrigation/Agricultural r Industrial n Water Quality Monitoring *SollSemplingIChafacterization <br />1 1 Public Water System <br />If dRraranl from O.mc: Water syatan Nama Contact Nama ar Phone Number <br />TYPE OF WORK U New Wol ! Replacement Well Wall Alleration/Modificallon n Other <br />n Monitoring Welge) 11 of wells �(Soll Borings) 3 _. s of txxlns' F Geotechnical s of borkl <br />U Out -Of -Service Well 11 Out-OfServlce Well Renewal n Cross-Connectlon Repair <br />Drilling Method i i Mud Rotary r Air Rotary )iAuger Cable Tool i, Pnsh Poinl i; Olhar <br />Proposed Wall Dopil r 1(14) Excavation In diameter -j Open Bottom u Gravel PacklGrovd Size in diameter <br />U Conductor Casing In diameter I Condvctor Casing Depth R <br />Wag Casing Olametcr N Thlckncss/Oaugc/ASTM Schad -1Steel 0 Plastic 0 Stainless Steel 011ier <br />Grout Seel Dept. R ,Neat Cement (9016 boo -10 Ual water) r Sund Cement sock m1x/7 Us[ water <br />0 BenteNle (20% solids) -, Other G9C'er BulLpuia 71., OCYr# g' -w w <br />Grout Placement Method _ Pumped u Free Fall X Other 17Lm rrt 1 ti n Retardant I Accelerator (name) <br />PEOESTA Installed By n Dr81er n Pump Contractor n Other <br />n Concrete Pedestal C Dimensions: Width_ ft Length ti Thlck In 0 Christy Box J Slove Pipe <br />PUMP USubmersible_ Turbine nOther HP Pump Set R 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. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AN IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS. <br />.9lNI t CE NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-7697 <br />SIGNED "` TITLE RME DATE Oct. 18, 2021 <br />Application Accepted 0y /L Z I ,- <br />Grout Inspection By <br />DEPARTMENT USE ONLY <br />Date J JE ) <br />Date <br />Pump Inspection By Dale <br />Soil Boring Inspection B ale \b i1 <br />COMMENTS <br />Area h ri 1 C4 ,Employee IDH <br />In SPECIAL Well Permit <br />U WAIVER RecelVed <br />Constructed Well Depth It <br />&E� MENT <br />E1 QED <br />OCT <br />'10A <br />NV/ <br />Ty p qQIJ/NCo� � Ty <br />ANT <br />PE SC Received <br />Codas into <br />Chackill Amount Date Permit/ Invoice WelllDd <br />e u t A <br />Cash Remitted L e a R-121± <br />L13 )dA <br />V LIU <br />ENoa.aa emrzole WELL muArPPEaLST <br />