Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1300 EAST MAIN STREET•EXPISTOCRES <br /> ON CA FROM <br /> -(AT ISSUED <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED W <br /> l _ _ CI YIZIP L <br /> JOB ADDRESS O b <br /> CROSS STREETAPN_ � ARCEL SIZE JLAND USE APPLICATION# <br /> PHONE <br /> OWNER NAME J ^�� / n <br /> OWNER ADDRESS -•ll� CITYISTATEIZJP '/-'—i• V A <br /> PHONE _ ` �_ ��� <br /> CONTRACTOR <br /> ADDRESS <br /> CR`r/S74TE/LP <br /> CONTRACTOR ADD <br /> PHONE <br /> SUBCONTRACTOR <br /> SUBCONTRACTOR ADDRESS_ Crry//STTATEIZIIPl1 _ <br /> LICENSE XC-57 � C-61 D D-09 D Other NUMBER ) ! `�VLIQ EXPIRATION DATE lO <br /> GEOGRAPHICAL INFORMATION: Coordinates X <br /> Y Township_ Range Section_ <br /> INTENDED USE DomestidPdvate D Irrigation/Agricultural O Industrial D Water Quality Monitoring D Soil Sampling/Characterization <br /> L Public Water System ame o ne �m <br /> It diff mnt from Owner. r y em ame <br /> JYPE OF WORK D New Well D Replacement Well 0 Well AlterationlModificationD Geotec <br /> p of 0 Other a of borings <br /> Monitoring We11(s) #of wells [i Soil Boringborings s) hnical — <br /> Out-Of-Service Well 0 Out-Of-Service Well Renewal D Goss-Connection Repair e— <br /> New Pu mp D Pump Replacement 0 Pump Re it C Raise Well Casing <br /> WELL CONSTRUCTION - <br /> Drilling Method '';Mud Rotary [�Air Rotary U Auger ❑Cable Toot -. Push Point 0 Other <br /> (Proposed Well Depth It Excavation in diameter U Open Bottom D Gravel Pack/Gravel Size in diameter xk <br /> D Conductor Casing in diameter / Conductor Casing Depth_ ft <br /> Well Casing Diameler_ln Thickness/Gauge/ASTM Sched U Steel C Plastic Stainless Steel Other <br /> Grout Seat Depth It C Neat Cement(94 lb b89/5-10 gal water) U Sand Cement sack mixl7 gal water <br /> D Bentonite(20%solids) 0 Other <br /> I Grout Placement Method 0 Pumped D Free Fall D Other D Retardant/Accelerator(name) <br /> EDESTAL Installed By D Driller D Pump Contractor 0 Other <br /> D Concrete Pedestal Dimensions:Width It Length ft Thick in D Christy Box D Stove Pipe <br /> L. <br /> PUMP Submersible0 Turbine 0 Other NP�_ Pump Set It Standing Water Level ft <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 /> OUR ADVANCE NOTICE REQU+'ry/PED FOR INSPECTIONS <br /> $IGNE9� TITLE_ V( T' DATE �D r <br /> 1 LL <br /> V <br /> I <br /> Y <br /> E E1 <br /> 1 � <br /> s�- <br /> DEPARTMENT U E ONLY <br /> f Application Accept B Date Area Employee ID#--!J <br /> _ Grout Inspection Date 2 SPECIAL Well Permit <br /> Pump Inspecbon B Date �y I WAIVER Received <br /> Soil Boring Ins on By Date Cons/truUedyVjJeII/D,epth ft <br /> COMMENTS � i/fi/ ^ 198fre-- eU ^��/ i'/7 !3121 <br /> PE SC Received Check Amount Date Pe'nitl Invoice N Well[DO <br /> Codes Info B ash Remitted Service R uest# <br /> L{`j vSo �f33 °� ► � S�-oot.n2�33 <br /> I <br /> EHD 43-M ' WELL/PUMP PERMIT <br /> 6W670e <br />