Laserfiche WebLink
' WELL/PUMP PERMIT THDIVISION <br /> ENTAL- <br /> ' WEBERAVE., ST O SERVI CA 95202 (2(9)468-3420 <br /> SAN 3OAQUIN 304E YE13ER A HEALTH SERVICES YEAROROM DATE ISSUED <br /> NON-REFUNDABLE PERMIT EXPIRES 1 <br /> IOB ADDRESS CITY(LIP ��tle p <br /> PARCEL SCLFIAPN L ADDRESS Poik <br /> 2Q <br /> OWNERNAME �-7n PHONE Z Z33 <br /> cITYaIP .a-� y ADDRESS 3 Q _77,7 <br /> CONTRACTOR ��yLPHONE <br /> C(TY2IP Y� TOWNSHIPS <br /> RANGE, SECTION <br /> ❑OTHER._�" <br /> GEOGRAPHICAL INFORMATION: COORDINATES X, <br /> ACEMENT WELL ❑ MONITORING WELL#------ <br /> TYPE OF WELL: ❑ NEW WELL <br /> 11 REPL ❑VAPOR EXTRACTION WELL#WELL SYSTEM REPAIR ❑CROSS-CONNBCT REPAIR � FIRST WATER LEVEL <br /> ❑WE — <br /> INSTALLATION: DEPTH PUMP SET <br /> ❑REPAIR H.P. ❑DESTRUCTION:— <br /> TYPE OF PUMP: ❑ NEW SOIL BORING <br /> ❑GEOTECHNICAL#� M <br /> ❑OUT-OF-SERVICE WELL CONSTRUCT( N SPF CONDUCTOR CASING DIAD <br /> TYPES ESL <br /> INTEL EE WELL EXCAVATION DIA� WELL CASING DIAD <br /> ❑OPEN BOTTOM <br /> ❑INDUSTRIAL WELL CASING TYPE SPECIFICATION <br /> ❑GRAVEL PACKISIZE' <br /> ❑DOMESTIC PRIVATE GROUT SEAL DEPTH�— <br /> ❑DRIVEN <br /> ❑PUBLIC/MUNICIPAL OTHER GROUT BRAND NAME <br /> ❑YES ❑NO <br /> ❑IRRIGATION/AG GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑MONITORING CONCRETE PEDESTAL BY DRILLER: <br /> ❑CHRISTY (j <br /> BOX L _ ❑STOVE PIPE $'U / --)K—CABLE— OTHER <br /> DEPTH AIR ROTARY AUGER <br /> APPROXIMATE SDt•�M <br /> PROPOSED CONSTRUCRILLING METHOD: MUD ROTARY <br /> TE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SAN <br /> IHE S <br /> gggY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE <br /> WITHTION/DHE WORK WILL BE DONE IN AC <br /> JOAQUIN COUNTY ORDIANCES, <br /> SIGNED: l �— DAr <br /> TITLE: <br /> DEPARTMENTUSEONLY <br /> Date T/Dr/�1__Area <br /> Application Accepted By I�� <br /> pate IfO Pump Inspected By Date <br /> Grout Inspection By �• 'b/�� <br /> Date <br /> Destruction Inspection By <br /> COMMENTS: <br /> PE SC AMOUNT CHECK#/ RECEIVED DATE PERMIT/SERVICE <br /> REQUEST# EL <br /> CODES INFO REMITTED CASH BY S R„0 x br7 Sv <br /> '( b <br />