Laserfiche WebLink
WELL/PUMP PERMIT 6,ff& five- KeC,-, <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION2 r �� <br /> 304 E,WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)465-3420 <br /> NON-REFUNDABLE PERMPT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS tC t tc a,4 APN <br /> CITY17.IP PARCEL SIZE <br /> OWNER NAME ZjV ADDRESS JL dJrl �P cS - <br /> CITY/ZIP— a4e r._ 4:523-7 PHONE <br /> CONTRACTOR- C 11- ADDRESS <br /> CITYIZIP TSIDS, PHONE(2L-YG) q423-13q5-----C-5 7 LICENSE#566�,.1.Z EXP DATE L <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑O <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER I� <br /> ❑OUT-OF-SERVICE WELL GEOTECHNICAL#— 9!Z ❑SOIL BORING ❑JESTRUCTIONSAN,I�j='-:_ :' <br /> INTENDED USE 1M OF WELL CONSTRUCIIONSPECHICATION ENVlRG"iP.�Fh+:•. <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DiA-AY;�L CONDUCTOR CASING DIA <br /> E3 DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLICJMUNICIPAL 0 DRIVEN GROUTSEALDEPTH S1PECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME f+ y iU X <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> Cl CHRISTY BOXGBDTEGKMCAL ONLY CONCRJ �A fSMT ❑NO <br /> APPROXIMATE WELL DEPTH Lf ��1� <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <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 C-57 LICENSE IS CURRENT <br /> AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNEn _,,E_5011�1lQicef _.... oATE��- 7-© <br /> 777777 <br /> BROOKOALE WAY BUTTON AVENUE <br /> ————�—.——W_...—.——.. —.--—— — <br /> -- —— <br /> Asrs"sn <br /> StlICY/!'s W7IX Ek6711C ` <br /> QRS wAv F"mv ISP <br /> c, a, <br /> a,WNIIDI sm nFw <br /> COTTAGE AVENUE <br /> DEPARTMENT USE ONLY <br /> Application Accepted ByWDate Area ,[_�_EMP <br /> Grout Inspection By Date *Pump Inspected By _Date <br /> Destruction Inset,By uST1NQ <br /> COMMENTS; No ctiEMIG <br /> PE SC AMOUNT RECEIVED DATE PERMITISERVICE REQUEST# INVOICE# WELLID# <br /> CODES INFO REMITTED CASH BY <br /> 14372 l5 z 3 [IZ5-1ED <br />