Laserfiche WebLink
I�PLUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUB HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304£.WEBEL', .E.. STOCKTON CA 95202 (209)468-3420 " <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YYFAf RFROM DATE ISSUED <br /> JOB ADDRESS -2-017Z /!x/nn00 /`/G�f/� _L__ <br /> PARCEL SIZFIAPN [� y� ,n�]e�pCITY/ZIP <br /> OWNER NNAANI"p�.I,�Pi�qL7[tJ[��1-�17.[L,J0IIAiDDRESS�� : ►/f _ - <br /> CITY/7_IP iy l4l�Vl -.�1 I -i J� 1 �L�PHONE �v <br /> PAYMENT <br /> CONTRACT R9m#m fimia ADDRESS <br /> CITY/LI 10 P}[ONF <br /> MAR 12 2@0-9 <br /> ur <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE_ SECTIO"IN COUNTY <br /> TYPE OF WELL: ❑ NEW WELL 13REPLACEMENT WELL a MONITORING WELL# `NAwAF+iEA��+FijA47N H+FRE5 <br /> IMSfE3hr <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR }I.P. DEPTH PUMP SET 171'. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SO[I.BORING _ 'K DESTRUGT[ON:- ,�✓�L���- <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACKISIZE WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLICIMUN1CMAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATIONIAG OTHER GROUT BRAND NAME <br /> ❑MONITORING 2,4 M R NOTICE GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE FO Fi A L_L CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPTH 1 N S P E C'T-I(D N S <br /> PROPOSED CONSTRUCTIONIDRILLING ME OD: MUp j 0 Y a,�R OTA Y AUGER—/- -CABL: OTHE 1:( i G <br /> 21 <br /> L- YSIr � -- IS� /! tt �L S'C��/d/GL�it 'f �12�-- <br /> I EREBY EAT Y T AVE PREPARED THIS AP IC ION AND THA THE WORK WILL BE DONE IN AC /�CE WITH SAN <br /> JOAQUIN COUNTY DIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SA;S JOAQUIN COUNTY.�-�y.�I lfY /01/rX-ef <br /> SIGN <br /> TITLE; ✓ DATE: O <br /> 2-4 <br /> WA I <br /> t I NIM I] <br /> DEPARTMENT USE ONLY �A��rr <br /> Application AccBy `1//'_O ,Arcacpled Dale - <br /> Grout Inspection By Dat Pump Inspected By Date <br /> _ � l - 1 <br /> bcsttaction Inspection By � Date_� �-L - <br /> COMMENTS: <br /> 0 ,�° <br /> PE SC AMO CHECK#! RECEIVED DATE PERMITISERVI REQUEST# WELL[Dk <br /> CODES INFO R E CASH B <br /> �� 50 a'1 1 6 �ROOaS uwt?o <br />