Laserfiche WebLink
7L _ <br /> WELL/PUMP PERMIT = <br /> ' <br /> SAN JOAQOINCOUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304EWEBER AvE3"FL- <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 F R INSPECTIONS s+'0VEARc1cTON CA 9W D TE IS 46&3420 <br /> EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRES4 <br /> CITY17A <br /> CROSS STREET — a <br /> f PN - - PARCEL SIZE Z-R ACLAND USE APPLICATION 9 � 4 <br /> OWNFAt NAME '�'��►'/ �IQ PHONE ? 3 <br /> OWNERADDRESS „VAr�1f!] CITYlSTATFJZdP <br /> CONTRACTOR <br /> f PHONE <br /> Ih CONTRACTORADDRESB-/��Fit�RAJK W-Is-r <br /> CITY/STATL'DPC <br /> A1. J <br /> SUBCONTRACTOR SP&C,r4,Jinvl YS' "pal[/ PHONE ""r <br /> SUBCONTRACTOR ADDIkM 2a6x�_�itf!!�.r1d �S� �, CITYNTATEMP 5:�M>Ai <br /> LICENSE C-57 ❑C-61 O D-09 Q Other NUMBER f 2 <br /> GEOGRAPHICAL INFORMATION: <br /> EXPIRATION DATC O <br /> AIATION: Coordinates X Y Township 2 S Ranga <br /> INTENDED USE ❑Dpmestic(Private D Irrigation/Agricultural O Industrial a>tf �� Section - <br /> Quality Monitoring O Soil Sampling/Charactmntion <br /> ❑Public Watcr SyygElcm <br /> Ifdifkrrnrirompamer +ter Yam <br /> mx ar u <br /> TYPE OF WORK �ilew Wel] Q Replacement Well O Well AlterationlModifcation Q Test Hole 0 Other <br /> ;KMonitoringWell($)_1 gofwells QSoilBoring(s) NotwhW OCxotechnical aefbodnar <br /> O Well Destruction. !�3 0 O ut-Or-Service Well O Out-0f-Service Well Renewal <br /> ❑New Pu Q Pum R D Pu Repair p Cross�orinection R it <br /> W ELL CONSTRUCTION <br /> Drilling Method Q Mud Rotary Q Air Rotary Auger Q Cable Tool ❑Push Point O Other <br /> Propured Well Depth_R Excavation <br /> in diameter Ell Open Bottom ❑Gravel Peck!Graver Size in dtameer <br /> Q Conductor Casing in diameter I Conductor Casing Depth ft <br /> Well Casing Diameter_2- in ThickneswUeugdASTM§0!� VO4 Q Steel Plastic Q Stainless Steel O Other <br /> GrautSwl Depth R XNeatCement(991bbag/S-10grr1warcr) OSand Cement <br /> Q Bentonite(20%solids) Q Manufacturer Spec%solids % Name 8"k mix/7 gel water <br /> Cruet Placement Method Q Pum Q Specs on File Q Spetx Submitted <br /> Pumped Free Fall ❑Other Q Retardant!Accelerator(name} <br /> PEDMAL jay �Dri]ler QPumpContractor QOther <br /> IConeretePedestal Dimensions: Width„-ft Len ^-�R Thick 1/ <br /> in Q Christy Boa Stove Pipe <br /> PUMP d Submersible ❑Turbine Q Other HP <br /> PumP Set R Standing Water Level R <br /> WELL DESTRUCTION Q Open Bottom 0 Gravel Pack Q Unused a Other <br /> Well Diameter -in Total Depth ft Depth to Water R Q Casing to be perforated flansfl to <br /> Sealing Material O Neat Cement(94 lb bog/S-10gal warn) d en <br /> Sand Cement fl <br /> Q Bentonite(20%solids) ❑Manufacturer Spec%solids % Name sack mfr/7 gal ware O Bentonite Papers <br /> Placement Method Q Pumped ❑Free Fall O Other - _ Q Spec$on File G Specs Submitted <br /> Q Complete with Mushroom Ca R below gmde O Complete to existing Surface Ped <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN A <br /> JOAQUIN COUNTY ORDINANCES, STATE LA D LICE I SAN <br /> I W3,AND RULES AND REt'+ULATIONS I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN C�r MYTM ALL <br /> WORKERS COMPENSATION LAWS, M V1 <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS fid j LUU9 <br /> Trrt.E QSAN�EENOAQUIN COUNTY <br /> Lj <br /> ., <br /> kip <br /> .. <br /> 5\ i / ter+. ` iY�' � r•••.f�B . <br /> DEPARTM <br /> N 6t/ <br /> Applicatielh Aceepfed-B Area <br /> Grow Inspection By EMptoyft IDN <br /> Da¢ o E3 SPECIAL Well Permit <br />' Pump Inspection By Date ❑ WAIVER Receiyed <br /> Destruction Inspection By eta <br /> Constructed Wen Dove A <br /> COMMENTS W 5 <br /> -FlJ L. <br /> E SC Received h Amount <br /> Codes Info B Cash Remitted Date Permit/ <br /> Service Request 4 Invoice N Well]DO <br /> IN22rM) hill l!� r ID / V J MASTER WATER WEU PERMR <br />