Laserfiche WebLink
WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE -STOCK rON CA 95201 -9939 I9n41AAR- A vn <br />,wn- rv.vUAt3Lt r'tKMI 1 WWW.Sjgov.org/ehd EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 5Z'); - \ .'-1 ` n G � t C ! 'A C '�- CrrYZP _of <br />411 <br />CROSS STREET CLQ `� t E (' I" l r/ • APN — r �j <br />M`[ _PARCELSREI S CI LAND USEAPPLICATION #/ <br />OWNER NAME t ` i t- r \ L -e ,M 1 -� V� `� PHONE k ✓ � V 0 .J C' <br />CJ <br />{ 7C <br />OWNER ADDRESS CIT1 K 11 t` y +� •tel J/ J/ <br />1 1 YISTATE(OP_ t <br />CONTRACTOR \I �) I '. 1� 1 } Y� `� PHONE _'j �-3(--q -moi ?779' <br />J �1 <br />CONTRACTOR ADDRESS L - iti C �, A CITYISTATE/LP <br />t <br />SUBCONTRACTOR/CONSULTANT PHONE <br />TANT ADDRESS <br />'AC -57 0 C-61 a D-09 <br />PARTY: D OWNER <br />CmISTATEIIZIP_ <br />C Other NUMBER 61 J� <br />C CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br />EXPIRATION DATE 7' 3 1 -1; Q <br />UUMesnc WELL SAMPLING: 0 General Mineral/Coliform Bacteria (43911 P Dihromnrhlnrnmmnano (d3Q9l r, e e , .� <br />INTENDED USE DOmestiCfPrivate C Irrigation/Agricultural D Industrial 0 Water Quality Monitoring D Soil Sampling/Characterization <br />0 Public Water System <br />Itditfemnl Gam Owner WmrSystem Name Contact Name or Phone Nur Mer <br />Tyor: r)c Wn '�'nle...,ec.,n--'---- _ - -- -- <br />r---- ---- .........................�. ..��....,a,uuurmwwm—un a umer <br />0 Monitoring Well(s) # of Wells D Soil Borings) s of borings D Geotechnical a or borings <br />D Out -Of -Service Well 0 Out -Of -Service Well Renewal D Cross -Connection Repair <br />Drilling Method dud Rotary 0 Air Rotary E Auger O Cable Tool D Push Point C Other <br />Proposed Well Depth G24 C ft Excavation j .S, in diameter 'I Open Bottom �,Gravef Pack/Gravel Size in diameter <br />D Conduct/or' Casing in diameter / Conductor Casing Depth ft <br />Well Casing Diameter Ua in Thidness/Gauge/ASTM Schad L- 96-' 0 Steel A'Plastic 0 Stainless Steel C Other <br />Grout Said Depth G R D Neat Cement (94 lb bag/5-10 gal water) {Sand Cement I C -sack mixl7 gal water <br />D Bentonite (20% solids) 0 Other <br />Grout Placement Method umped 0 Free Fall 0 Other C Retardant / Accelerator (name) <br />PEDESTAL Installed By Driller D •Pump Contractor _ D Other <br />71 Concrete Pedestal ❑Dimensions: Width ft Length ft Thidcin❑Christy Bax ❑Stove Pipe <br />PUMP *Submersible[] Turbine 0 Other HP Pump Set --_ft Standing Water Level <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 />._(.'yl i j' 8 ? ti R �iDl �^,i, LCE .OTi, E REQUIRED FO a11!Sa 7CrlCi t3 - P =t SE CALL (091 953 -Mi <br />M <br />A MENT U E O LY <br />Application Accepted By ate Z Area Employee <br />Grout Inspection By Date 7� ❑ SPE AL Well Permit <br />Pump Inspection By Dale L WAIVER Received r �r <br />Soil Boring Inspection By Date Constructed Well Depth 4j�ft <br />COMMENTS <br />I%l1, QaItM!,RIAi <br />.a�a �� �. I (g��332- WELLIPUMP PERMIT <br />