Laserfiche WebLink
WELL/PUMP PERMIT <br /> bl.•e JOAQL'I.4 Cov.,ayENIi Ro%M fJWAL I I FALT It DEPARTs1EhT 30IE\5'EeERAA"E3"FL•SToc KTov CA9520T -(I09)08.3410 <br /> NON-REFUNDABLE PERMIT CAI 1 209 953.7697 FOR INSPECTIONS EXPIRES 1 YEAR FRONI DATE ISSUED <br /> //o///ass 11 <br /> JBA ADDRESS a c��Q X1e- rj C17Y21P_ �f!11��-7 <br /> SCI-ELC'L�F�� APV p�Qq A30 1r PARCELSIZE� 1 tl <br /> CAOSSSTREET _ D• LAND USE AP`P+LICA�jTIO`tk ^T to <br /> OHINERNAAK y-�Vl 1�-r ,, I "_• PHONE <br /> -r�7�0j'/-')�c- a00__ /0`7�3 {TA7 <br /> OHIERAI ESS 1 • LM L& CITYISTATFIZIP 6(fr sC W Pi t1000 <br /> CONTRACTOR �- 2" ; PifoNE 9QjT�-/l�3y-33�f9�a <br /> CON-T RACTOR ADDR[SS_Q i� Oe�'cJC. �5 _" CI 'fSTATFIZIP-_ 6/�/ f <br /> SLICONTRAC'TOR PRONE <br /> SvOCONTRACTOR ADDRESS _ CtTVtSSTATE21P �I_ <br /> LICFl:SE C•ST ClC-61O D09 ❑Olhef NUAIEER J !2GL/Lf ElPIMTFOV DATED <br /> GEOGRAPIIICALINFOFMATIOS: CoOrdlnales X Y Toernhlp` Ranze Setllon <br /> INTEhmo USE U>mestit/Pri+ate ❑Irrigation/Agricultural 0Industrial O Water Quality Monitoring- O Soil S.xnpliny1CharutM,%6on <br /> D Public Water Seems <br /> Ifdit(rarfn�a •er - utr )v<a ama �_ms—Ps1s —I, <br /> TYPE OF WORK }y Kew Wc11 D Replacement Well D Well AlttratioNModification D Test Hole D Other <br /> ❑MoMwfing Wells) Rofwclis DSoil Wng(s)." adh:v:p 0GMNhnical ,aoit,:ruyy— <br /> D 0%:1.06Se(,ke Well D Out-Or-SCMCC\eil Rent'll <br /> ❑New Pump ❑Rmp•epltument D Pum Re sir O Cross-Connection R itWELL,CONSTRUCT IOY <br /> Drilling htethod )4 Mud Rotaryr D Air Rotary D Auugt�r(1 11 Cable Tool O Push Point D Other <br /> Proposed Weil Depth_yU_R Excavation /d/YI in diameter D Open Bottom D Gn,el Pack/Gnvel Siu__._"_Tin diametei <br /> DConduct Casing indiameltr / Co.,,i'uc(or Casins Dapih R <br /> Well Casing Diameter in Thkkr&ss'Gauge/ASTh1 Schell SOP--•21 D Soul Plastic D Suinlus Steel D Othtr <br /> Grout Seat Depth R DNeat Cement(pElbbog/5.10galnaler} SsndCement �10•.g sackmrrl7gal%alet <br /> DBenionite(26%solids) 0ManuraauretSpec!:solids^': Name DSpccsoniile DSpecsSubmlrLd <br /> Grout PI■cement Method D Pumped D Free Fail OOth_er D Retsfdant/Accelerator <br /> PEDESTAL Installed By 0Driller )d Pump Contrafor DOther <br /> XContrele Pedestal Dimensions: Width R Ltngth__L."rt Tbick_L&_in D Christy Box D Slort Pipe J <br /> PUMP D Submers+ble D Turbine O Other _ HP Pump Set R Standing Water Lecei <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN .A <br /> JOAQUIN COUNTY ORDINANCES•STATE LAWS,AND RULES AND REGULATIONS. )'ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE 89TH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT i Abf IN COMPLIANCE SVITH ALL <br /> WORKERS COMPENSATION LAWS. .. .. _ y <br /> N 1\fUM 24 HOUR ADVANCE NOTICE REWJIRED OR INSPECTIONS <br /> SIG.\ED TREE �G L. DATE <br /> sb� 12 R. S. 178 <br /> 190 a <br /> e N <br /> PROPOSED <br /> 19� PAPCEt A' F D <br /> ` s �vim.. coq-•�S,o.•�o � f' <br /> u. c 192 tai 05 <br /> t5 n i- <br /> 19h $Ali 10N] )NTY <br /> t .. FiIV\rt <br /> •TOAD To • If3f R HEALTH ILt(T <br /> rY ROAD 144 <br /> 196 pb Lf <br /> r —196 <br /> ` _ JIXFEO F1'44'KI <br /> ----- �U,C—eA'kTSt77'r-r- vry <br /> Application Accepted By ate ' 1r3 Q..S' Area ��(<' Employ"IDN <br /> Grout Inspection D Date ❑ SPECIAL Well Permit <br /> Pump Inspection By Date__ 1VAIVF.RReeelved <br /> Destruction Irspecalon By Date Conslrutlyd Wall Depth (1 <br /> COMMENTS ) <br /> PE SC Ratlrtd ec Ll Atmouol Dale 15'elI1DJ <br /> PtrmiU I <br /> Codes Info B' ash Rn9tted Sel"A(tR Request <br /> Ioroke0 <br /> q31116 6- yyl 99 a>;s(iU *16 6ROO ( 02 p2oz <br /> - - <br /> EHD(1-01{.'J. -- ATLL tlN?rERA11T <br /> A'f.C1 <br />