Laserfiche WebLink
WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 <br /> 1 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS ` S CN vlls� (01 <br /> PARCEL SIZE/APN CITY/ZIP \1 \w"A 2Ls.A <br /> OWNER NAME, Ny-c, ADDRESS e��_AgL\�Q. <br /> CITY/Z1PS �q- ys33'� PHONE ao3g1 _�'j o1� <br /> CONTRACTTOR \Ve�S���utc\ y�y II�DDRESS <br /> CITY/ZIP ..7 OC.�1�-. bN �� v���JPHONE �� <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> I <br /> INSTALLATION: WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: NEW ❑REPAIR H.P. DEPTH PUMP SET SFT. FIRST WATER LEVEL \IAt ! <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CQNST�TION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> YDOMESTIC <br /> PRIVATE 13 GRAVEL PACK/SIZE WELT, CASING TYPE WELL CASING DIA (_S��� <br />` ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> i� ❑IRRIGATION/AG OTHER GROUT BRAND NAME ! <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO r <br /> APPROXIMATE WELL DEPTH <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 ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIG ' N <br /> TITLE: 4 DATE: <br /> I <br /> Ln <br /> LVUY I <br /> ZEE <br /> -1 <br /> i <br /> I <br /> I <br /> I <br /> I <br /> ,DEPA TME U>15 ONLYE; <br /> Application Accepted By Date Area--3741 <br /> Grout Inspection B t <br /> P Y Date Pump Inspected B Date <br /> Destruction Inspection By Date <br /> COMMENTS: <br /> PE SC AMOUNT ECK# RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# i <br /> CODES INFO REMITTED BY <br /> 0'2 `/may LPS f°� 1 pC _ <br />