Laserfiche WebLink
4` WELL 1 PUMP PERMIT <br /> SANJOI,QVIN 0dUYTV ENVIRONMENTAL HEALTH DEPARTMENT 304E WEBER AVE 3MO FI.-STOCItTON CA 952.02-(209){60.3420 <br /> NON-REpurvDABLE PERMIT CALL 209 9L3-7697 MR I N%rECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> _ y <br /> JOBADDRESc G-1 a . CrrY21P <br /> gY <br /> f <br /> C2- > <br /> 2 p <br /> I pDs4 STREET �ti �ro.1 AFN Kh. ���'Z 7PARCEL SIZE 1 pL � LAN➢UST APPLICATION M <br /> OWNER NA.mE .-',Lc.­­iC.. PHONE <br /> OWNER ADDRESS 1�'� �fdaC U CrrYISTATXMP <br /> COMRAG-1'OR _c'1 ! , PtloNc - 3i*%- "Van <br /> t <br /> CONTIIACrORADDRESS R.. 6w� CITYISTAT.7o <br /> SUBCONTRACTOR PHONE <br /> SURCONTRACTOR ADDItM CITYISrA/TL P <br /> LICENSE C-57 d C-61 ❑D-09 ❑Other EXPIRATION DATE <br /> CEOGRAPHIC:ALINFORMATION: Coordinates X V Townshfp_i Raoge Section_ <br /> INTEN➢Eo USE 0 Dumestidprivatc Q lrrigationfAgricullural 13IndustriWa <br /> al ter QUslity Monitoring 13 Soil Somplinf/Chaeacterization <br /> Q Puhlic W arer$stern <br /> ' 1ldtn'ererr fiam wnrr uer yttem rn,e ocr arse ar n< � <br /> TVPE OF WORK ❑New Well ❑Reptacemcen Well ❑Well AlterstionNod,fication ❑Test Hole Oothar <br /> $JvtonitoTingWell(s)___L_#of wells OSoilBoring(s) anrba W 0Ge:olechnieal aa(bonnip <br /> I <br /> C3 Wclf Destruction ❑Out-Of-Service Well M Oat-0Y Servicc Well Renewal <br /> ' El New Pum ❑Pump Re latement D Pump R air 0 Crus-Connection Repair - R <br /> I WELLCO`RTRULTIOH <br /> Drilling Method ❑Mud Rotary ❑Air)tolary XAugeT ❑Cable Toal ❑Push Point 0 Other <br /> Proposed Well Depth 25- R Excavation 6 in diameter O Open Bottom Pack!Gravel Size in diameter t� <br /> ❑Conductor Casing in diameter ! Conductor Casing Depat p <br /> Well Casing Diameter ;�in Thicknesa/Gauge/ASTM Sched �JU El Steel Amastic El Stainless Slee) ❑Other <br /> Grout Seal Depth R <br /> .Neat Cement(94!h hog/3-lDgrrt„nrBr) C Sand Cement cock mG!?g11 venter <br /> f]Bertron)re(2095 solids) ❑Manufacturer Spec%solids_% Name_ 13 Specs on File ❑Specs Submitted <br /> Groat Placement Method 13 Pumped KFTeo Fall ❑Ocher Q Retardant!Acceloralor{name) <br /> I PEDESTAL Installed Sr 0 Driller ❑Pump Contmcmr Q Other <br /> ! 1 0 Concrete Pedestal Dimensions: Width R Length it Thick in Cl Christy But 17 Slave Pipe <br /> PUMA O Submersible ❑Turbine ❑Other HP__ PUmp Set A Standing Water Level ft ) <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> IOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY REQUIRED LICENSE IS r <br /> t CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> NIiN 2 OUR ADVANCE NOTICE f REQUIRED FOR JNSPEC'r ONS cJ <br /> SIGNED TfTL.E 47 lit ttiCL'kw.•Ltt-t-�11 DAYS <br /> ".c`F':. =•�- r_"-=�r=.\��� �.v.s_'Y%i1� t..` <br /> LLL I <br /> B <br /> r ` <br /> _ - cis r D <br /> LEGEND <br /> sal mTAL <br /> LETI <br /> i <br /> �tJ <br /> s s I} <br /> DEPARTMENT VW �NI, / <br /> .r A.Application Accepted By Date A6mpioyee IDI[11�' <br /> Grout Inspwtion By Date 7J ❑ SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Destruction inspection By Date Comitructed Well Depth If <br /> PE SC Received cher Amount- Date Permlll invoice N W01 IDN. <br /> Coder Into B Cash Remitted Service Re hest f7 <br /> IC-fiC3 c" <br /> END 47-07.04 WELL PUMP PERMIT <br /> LF/e/ <br /> J <br />