Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
NON-REFUNDABLE PERMIT wWW.s • ov.or /ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS .3:.&' I I Nc..."or viCir"C cirazip ircIA ftel 9:5:-.3 ..<;..7 <br />cRoss sTREETeion z--t, 1? r it f011e,Aplf'' ,; L.1 I .)t:C) ii? PARCEL SIZES 44 ' tic LAND USE APPLICATION It <br />OWNER NAME P O. 0.0010,,i ti-c, tic. aimr.,t.t-C c/o Tem- G7144 4 a 4 4 n r- HONE <br />OWNER ADDRESS 1 1;10 6/ • EQ44 +CA. (1.0-n1/4 51-. CITY/STATE/ZIP-Qui, Tae„ / CA/ q51 / 1 7 <br />if ii-svoc4-c.4-t5 ,I. <br />CONTRACTOR ADDRESS , I 2. iv aL,,,,,-p.... 4, CITY/STATE/24P N.cA C46 <br />SUBCONTRACTOR/CONSULTANT ffi dr ilivt.• PHONE C 25) <br />SUBCONTRACTOR/CONSULTANT ADDRESS 110 Wave fit ciTy,sTATE.,,,...,..th...._ (7, <br />LICENSE X C-57 3 C-61 L D-09 0 Other NUMBER 1°411415 4' EXPIRATION DATE <br />BILLING PARTY: <br />CONTRACTOR PHONE (I 25) 467 <br />A / 55 <br />— IC/7- 2. <br />eksevi <br />4. <br />3 OWNER )(CONTRACTOR 0 SUBCONTRACTOR/CONSULTANT <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HA/ELTON AVENUE -SToctcroN CA96206-6232 (209)468-3420 <br />DOMESTIC WELL SAMPLING: U General Mineral/Coliform Bacteria (4391) 0 Dibromochloropropane (4392) 0 Arsenic (4393) <br />INTENDED USE 0 DaMeStic/PriVee 2 Irrigation/Agricultural LI Industrial 0 Water Quality Monitoring KSoil Sampling/Characterization <br />ri Public Water System <br />If different from Owner. Water System Name Contact Name or Phone Number <br />in <br />TYPE OF WORK 0 New Well 0 Replacement Well 3 Well Alteration/Mod:fication C Other <br />IT Monitoring Well(s) ft of wells 1 Soil Boring(s) Cal bcftr9, Neotechnical E el borings <br />0 Out-Of-Service Well 0 Out-Of-Service Well Renewal 0 Cross-Connection Repair <br />U New Pump 1J Pump Replacement U Pump Repair U Raise Well Casing <br />WELL CONSTRUCTION <br />Drilling Method II Mud Rotary ',Air Rotary I Auger i i Cable Tool I Push Point I i Other C. <br />Proposed Well Depth —04 Excavation In diameter 3 Open Bottom 0 Gravel Pack/Gravel Size in diameter <br />ID Conductor Casing in diameter Conductor Casing Depth <br />Well Casing Diameter in Thickness/Gauge/ASTM Sched 3 Steel <br />Grout Seal Depth 0 -13Q/ )(Fleet Cement (94 lb bag/5-10 gal water) <br />0 Bentonite (20% solids) 3 Other <br />Grout Placement Method 3 Pumped 0 Free Fall A Other 4- (9V 0 Retardant I Accelerator (name) <br />PEDESTAL Installed By C Driller 0 Pump Contractor 0 Other <br />0 Concrete Pedestal :Dimensions: Width ft Length <br /> ft Thick in C Christy Box D Steve Pipe <br />PUMP <br /> 0 Submersible C Turbine 0 Other HP Pump Set ft 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 />MIn1,11M 4.8 I-LOUR ADyAltr...E-NOTICE REQUIRED FOR INSPECTIONS - PLEASE CALL (209) 953-76,7 <br />SIGNED N ikr(p.A. TrrLE AS ...k1& DATE (0 /%172j <br />°€) <br />/vto Jo/ <br />J0,4 <br />z 3 2 0 2 <br />1 <br />NI/ QUi ril/ROA/4,7/VCsouN <br />ft <br />0 Plastic 0 Stainless Steel r Other <br />11 Sand Cement sack mixI7 gal water <br />$A <br />p. <br />a 9 (A' <br />Area 'ilfra::44.1i1:4•Ernployee IDft A 'S ApplIcallon Accepted By <br />Grout Inspection By Date 0 SPECIAL Well Permit <br />Soil Boring Inspection By <br />Pump Inspection By Avig. Date 0 WAIVER Received <br />Date 7 --ir- zei7e Constructed Well Depth ft <br />COMMENTS <br />PE <br />Codes <br />SC <br />Info <br />Received Checkitt Amount <br />Remitted Date . Perrnit/ Invoice # Well loft <br />1 '50 1&L 3 — .1,2.-- 4i i?) i; <br />_ .54 <br />' ' 2'5 <br />4,5vtiNgt.t <br />vitt/ <br />_ -..› ... <br />DID 43-06 6/11/1019 1.272 +4, 4.13 7._WELL /PUMP PERMIT <br />DEPARTMENT USE ONLY <br /> Date