Laserfiche WebLink
WELL/PUMP PERMIT � <br /> SAN JMQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEAL,TH DIVISION <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT�E(��MRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS S/ `, �.-�•��� /�PGI.X-9t"-lll G/ t _APN 7 Z�F��C> <br /> CITY4 0 `f^�y'!7i ! S3,3 �7 /�• PARCEL SIZE 2 S <br /> OWNER NAME Ak 61?CIAlf ADDRESS 0•6�GlC�Y> <br /> Crrvrz'P 1'"lOC(QS�a �,�- 953S�-O'7yS PHONE <br /> CONTRACTORy--.�• �. AQr5-IFI 12191a 5-7XC ADDRESS_ _&29TLII�y IC IJ <br /> CTi'Y1Z1P /l'�4C/pS� CA• PHONE Q e9+LICENSE# 7666�EXPDATF7_3/� <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP_ RANGE—SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONMORING WELL# BOTHER <br /> INSTALLATION: ❑WE* ITEM REPAI <br /> SR CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> / <br /> TYPE OF PUMP: �ivEw ❑REPAIR H.P. :3(9 DEPTH PUMP SET O�E ._Fr. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHN[CAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> t <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE (17^J t <br /> WELLCASWG DIA I <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUTSEALDEPTH SPECIFICATION V� <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: O YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> N <br /> APPROXIMATE WELL DEPTH <br /> c <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY_AIR ROTARY AUGER CABLE OTHER <br /> 1 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 /> INIINIUM 24 IIOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED /��%C \! -rmF �/LSC1d0�/�" DAAL <br /> tt,1�D� <br /> It I <br /> L <br /> e <br /> I <br /> D ARTMENT USE ONLY <br /> Application Accepted By pat. y L <br /> ✓Area EMPID# D7 <br /> Grout Inspection By Date Pump Inspected By /1 pate <br /> Destruction Inspection By _ Date <br /> COMMENTS: <br /> PE SC AMOUNT RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL ID# <br /> CODES INFO REMrITED CASH BY <br />