Laserfiche WebLink
L0 32-1 <br /> • W ./PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLd41EAL-M SERVICES ENVIRONMENTAL HEALTH DIVISION �I , <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUEDQ/'r,. <br /> JOB ADDRESS' <br /> CII'1'!Zp_1 t / U 135 z 7 0 C PARCEL SIZE `1 C'•+(FCC ,�s3 <br /> OWNER NAMEPOD j N f 1 / ADDRESS)yZ'I—f 7 K C T1 E 044\J40 , <br /> CrIY/ZIP�.t7( 1((-��z> L� `7 5 J ' PHON���q <br /> CONTRACTOIC4i7'Z �UI7 )'AU I A S W.y I�J(.ADDRESS': �. "' l eU <br /> CITY/ZIPf'.();'I . (,A C/5 G.4 Z PHON9101) i�oj ' 50 to C-57 LICENSE# �" EXP DATE''3 <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y " TOWNSHIP_ RANGE_ SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# t/O OTHER I E' 1 l L <br /> TT <br /> +4�T <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLICIMUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PIMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY_AIR ROTARY AUGER CABLE OTHER <br /> �A <br /> I 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 /> �PINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE''Arf fNC,ItliEfi� DATE °" <br /> :44 <br /> 1. <br /> If <br /> t t . <br /> I <br /> 1e' i; <br /> i <br /> 1 t <br /> I I <br /> ARTMENT USE ONLY <br /> Application Accepted By -A2'.' / Dace '� GZ Area 1 EMPIDIt <br /> Grout Inspection By Date Pump Inspected By Date <br /> Destruction Inspection By n,Re <br /> COMMENTS. <br /> PE SC AMOUNT #1 RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL 1D,# <br /> CODES INFO REMITTED, CASH BY <br />