Laserfiche WebLink
... WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 <br /> h NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED 9 /� <br /> JOB ADDRESS c v I S E� /V APN / / / / / V� <br /> CITY/ZIP PARCEL SIZE 2 <br /> OWNER NAME ' �- >l'.�'—N�—= ACDDREESS�1�. y / Ctn c3- <br /> CITY/ZIP L c` / 7 S PHONE / L `S— c� Y — .7 0 C U <br /> CONTRACTOR ADDRESS <br /> CIT_Y/ZIP PHONE C-57 LICENSE# EXP DATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# '16 OTHE <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR O 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 /> O INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA__ CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELLCASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEP'T'H <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 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 /> MkNIMLIM 24 IIOUR ADVANCE NOTICE R ' 2EU FOR INSPECTIONS <br /> 51GNEDTITLE DATE <br /> ry <br /> _ V <br /> I - <br /> ' jfjI <br /> .1 )/ ) <br /> p DEPARTMENT USE ONLY <br /> Application Accepted By f"1 I c", 1� S�ti Date Arca EMPID#� <br /> Grout Inspection By Datc Pump Inspected By C. Date U )-0-O I <br /> Destruction Inspection By <br /> � Date <br /> COMMENTS: <br /> /01/311�U[) <br /> PE SC AMOUNTCK#/ RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL ID# <br /> ITT <br /> CODES INFO REMED ASH BY <br /> ZZ <br />