Laserfiche WebLink
ft WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 3M WEWt AVE 3-FL-STOCNTON CA 115202 -(209)668-3620 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES I YEAR PROM DATE ISSUED <br /> Alan <br /> JOBADDRE53 S / CITY/ZIP <br /> CR STREET PN, &,T—m 9fQ— ARCELSITLLANDUSE APPLICATION# <br /> Owl",NAME Dl^IQM d- LSat �CYN/jL��ia^ON1� Gsn PHONE <br /> OWNER <br /> OWNER ADDRPbB IS7SI SSe VLLN /��/�M CrrYhTATVLIP <br /> CONEM R EV a Ci-1,,/6/Ir< UP/ �/Ag PHONE 2— V <br /> CONTRACTOR ADDRESE I q 4ILIF CITY/SEATEZP <br /> BUECOryTpACTOp PHONE <br /> SUBCONERACEORADUREFS CITY/STATEIZIP N <br /> LICENCE 6-57 OCdl (70-09 Dothan NUMRuc ENnHATtoNDAT <br /> GPAORAPHICALINPORMATION: CNr .M % Y TCwnahlp_ Rutga_ SeeUon_ <br /> 7"E"USE ;Mie/Pnvam 0 bdpdon/AgdCYIaTAI Oindusawl 0 Waw Quality MMiWnng 0 Be,]SamplioP/Chalactenation <br /> 0 Public Water Sar <br /> yc <br /> Ifdiffemtfn. x 7"E" am E.'nn iom owu.anwm <br /> TYPE OF WORK New Well 0 Reykcement Well O Well AlanatioNModifiatim 0 Test Hole ❑Met C^j <br /> 0 <br /> a Cfannp xaad� �jII(O <br /> 0 Monimring weli(s)_#Of wells Soil Bonng(s) 0 Geotcchnlcal <br /> 0 Well Deshucden ❑Out-0f-Service Well ❑Out-0f-Service Well Renewal <br /> ❑New Pump 0 Pn.p R hicernelt ❑Pum Repair OCmM-Co..and.Relan <br /> WELLCONSIRUrn <br /> Il I Method P&d ROMry 0 At,Rotary 0 Auger D Cable Tool 0 Push Point 0 Other <br /> Pmposed Well Depth III R ExavadonI� in diameter ❑ON.B woo, 1Cimvel Pack/Gnvel Si. in diamuer <br /> ElGoducmr ;ng indiamew / Condww� 99 <br /> rr Casing Depth - ft <br /> Well Culog Diamew , n ThwknuWGaugdASTM Schell�A _ 0 Steri A(Phade 0 SUd-I—Steel 0 Other <br /> Grout Seal Depth ft ONat Cemenl(96/6bng/3-lOgo/wprer) ❑Sand Cement .rock Mirl 7 gal waw <br /> )4awnite(20%solids) OManufM.Tuw Spa IN,solids_% Name OSperson File 13 Spent Submittd <br /> Cmut Placement Metbd meed 0 Fres Fall 0 Other ❑Reuldut/Aaelentm(name) <br /> PEOESTAL Inslalkd 0, 0D,Llcf 15QUmp Contramt ❑Other <br /> ❑Ceacmw pdeMNl Dimenaam: Wie tl L cegth ft Thick in O CbrIo Boa O Show Nps <br /> POMP 0 Submersible 0 Turbine [30th HP Pump Ser ft Sliding Waw Level ft <br /> 1 HEREBY CERTIFY THAT 1 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 1 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 /> I I /� y�/M�INI�MUM 7,4 HOUR ADVANCE NOTICEa�REIQU IRED FOR INSPECTIONS <br /> 1y4,je � <br /> SNRIEDyle, �/ TITLE 1]MLII�✓r DATE�JL���-QS <br /> C <br /> gj <br /> J UI U c'/ <br /> 'lyA DEPARTMENT USE ONLY �7� <br /> Application Acaphnd By I` ' L fe Da¢T]^DSS Arta Empbyee lDO_0,0 I�T,,- <br /> Gmut Inspection Date Li_ �_ ❑ SPECIAL Wtll PDElltit <br /> Pump Inspection BY Date ❑ WAIVERRDEEived <br /> Duwction Inspadm By Date Coustruetd Well Dept11 ft <br /> COMMENTS <br /> PE SC Ranutali Cbaekw Anlpaat Dun PaIRgW IRvoioe# WNI IDM <br /> billowCodu Ivfv 8 Cub ReMtted Service Requill,M <br /> /I{�1 7yi IQs Jf D ZO DO 24Z! <br /> fiXDe]-03-0b WELL PUMP PERMIT <br /> a6e1 <br />