Laserfiche WebLink
v%(Itr.1 SL�I� l•zy_i� 05�� <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 18158 EAST HAZE.TON AVERIM - STOCKfON CA 95205 - (209) 4653420 <br />NON-REFUNDARI PERMIT �jCALL 209 953-7697 FOR INSPECTI(M rEXXPIRES 1 YEAR FROM DATE ISSUED <br />IJoe ADoREss i • �� n CITYA "eI /V� C�C <br />CRoss STRF EP APN f/j]y���� 0 L� PARCEL SQ$ 112F APPLICATION # <br />OWNER NAME On U f --T PA [ \� <br />OWNER ADDRE5 <br />—yam-1- JjYAe2i% <br />LJ <br />CONTRAC <br />Coxrn ov` <br />a Ac !� (/t y CmISTATM& "` S <br />SUBCONTRACTOR PHONE <br />SUBCONTRACTOR ADDRESSCrryfSTf/A�T;T?MP I / <br />LICENSE C-57 /C-61 D-09 QO —N <br />GEOGRAPHICAL INFORMATION: Coordinates X Y <br />Township _ Range_ `\ Section_ <br />INTENDED USE Domestc/Private Irrigation/Agricultural Industrial Water Quality Monlonilg Sod Sampliing(Characferdation <br />Public Water System <br />It different from Owner Water Or <br />TYPE OF WORK New Well Replacement Well Well Alteration/Modification Other <br />MonitoringWell(s) lit of wells SoilSoring(s) #0lo0t p . Geotechnical <br />Out-Of-Serv-f.* tl Out -Of -Service Well Renewal Cross Connection Repair <br />Drilling Method Mud Rotary Air Rotary Auger Cable Tool Push Point Other <br />Proposed Well Depth ft Excavation in diameter Open Bottom Gravel PaddGravel Size_ in diameter <br />Conductor Casing in diameter / Conductor Casing Depth R <br />Well Casing Diameter _ in Thidvress/GatrpetASTM Schad Steel Plastic Stainless Steel Other <br />Grout Seal Depth ft Now Garment (94 lb baa/S10 gal watar SanH Cement sack mod? ;al water <br />Bentonite (2C% solids) Other <br />Grout Placement Method Pumped Free Fad Other Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller . Pump Contractor Other <br />Concrete Pedestal Dimanskrns: Width _ ft Length h Thkk in : Chrtaty Box Stovepipe— <br />PUMP <br />tovePiPUMP V Submersible Turbine Other HP Pump Sot R Standing Water Level ft <br />HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPUCATION 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 />MIN UM 24 HOUR ADVANCE NO/�J{TCE REQUIRED F R INSPECTIONS <br />E/CT'II'ONS - P // E CALL (209 53-7697 <br />SIGNED .GJG,C/.! TfTLE I ✓ lX f r� I Y DATE <br />110 —T 7T�`� <br />W <br />A <br />CEIvVyLD <br />04 2 3 201? <br />—a�a�a�aMlls� a�r�u .t.—sann—rsl�I�� ;Mmmmwtq►ft11:'� ..T <br />1:11■■■■■■■■■■■■■■r■ !1■�li� I■■m�(■■■■■■■■Immo■■■T . . <br />Rill..—r---------------�--------�—IN—�■■■■■■■■■■ .. , <br />i■le■■■■■■■■■■n�a�r�■.��nr�■r�►►�■■■■■■■■■■■■■■■■■■■ <br />a <br />Grout Inspection By <br />Pump Inspection By <br />Z;"27 '7— It 6, 3,3 WELL IPUNP PERMIT <br />