Laserfiche WebLink
WELL/PUMP PERMIT Zd> <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E,WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 `4 <br /> �7 NO -REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDQD�l�✓ <br /> JOEL ADDRESSr�'Y t/" �—` APN �T br! Z� r0O-! , 0 <br /> CITyrztP p gt$'' �3p DLA O / 403: 1 <br /> A 6-0T*� Pt+�E . * . <br /> NER AME /��` ► e ADDRESS-6 O 1 S • - � !�u ZO- 5T— <br /> OWNERNAME �) <br /> CITY/ZIP <br /> CONTRACTOR— ADDRESS <br /> C1TYrLip � al�Z� PHONE f y f y C-57 LICENSE# �7�EXP DATEY" <br /> Z <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION_ ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET Fr- FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL GEOTECHNICAL# I U 13SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECPTCATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA _ CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME /Aft-640L a—C+1 <br /> Q MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRQ.I.ER: ❑YES ❑NO <br /> 1 <br /> APPROXIMATE DEPTH <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WELL 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 WTTH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> M HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE <br /> awn-isIAet r. <br /> JR <br /> iY 4 <br /> r Y Cf <br /> �� RFS �a( <br /> � 'r•. <br /> f MELLOM Tg • <br /> BOSTON SAFE pEpp s CSC <br /> y^ <br /> APN 198.130-pay <br /> NESTLE 1.54 <br /> rw „- <br /> 3 ,�f <br /> D PARTMENT USE ONLY <br /> ;By ` te Z7— U <br /> Application AccepterEMPID# <br /> q'37 <br /> Grout Inspection. Da Pump Inspected By Date <br /> besttuctian Inspecti n B _A9Date <br /> COMMENT'S; �` K <br /> PE SC AMOUNT CHECK RECEIVED DATE PERMITISERVICEREQUEST# INVOICE# WELL ID# <br /> CODES INFO REMITTED CASH BY <br /> a 57 Yd 7 as i�1 Poco z�r� <br /> 100 aA 0 0 �2 L/ Iq 3 r <br />