Laserfiche WebLink
WELL/PUMP PERMIT [yam_ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DI ' f4 C <br /> 3041-WEBER AVE, STOCKTON CA 95202 (209)468-3420 4 <br /> NON-REFUNDABLE PERIyi]T EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS z Qau e��t^-A Cta.yn[> �V�A[y(C7 --- � f� r (� <br /> PARCELSIZFJJAP�N_ / V fi YY S CITY/ZIP h (U 1 if UX(/J _. <br /> OWNER NAME. 1Y, tT011AJ�t+Jit�C��I- ADDRESS - <br /> CITY/m Cr4r'I Loa;S PHONE - _ 3,Za <br /> CGNTRACI'OR ,O 1�.Ml.�y,'1A-tY ADDRESS <br /> CiTY/21p^I�O r.,,);I C(�t !tn<< PHONE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y_TOWNSHIP RANGE_SECTION <br /> TYPE OF WELL: 1f NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# <br /> ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR C3CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: #t NEW ❑REpAIR ILP. DEPTH PUMP SEI /�-I FI, FIRST WATER <br /> LEVEL I U(7 <br /> -OF-SERVICE WELL ❑GEOTECHNICAL CAL 11SOIL BORING <br /> ❑DESTRUCTION: <br /> NtENDED USE _TYPE OF WELL CONSTR CTI N&ZgffjQnON <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA <br /> 2p� CONDUCTOR CASING DIA <br /> ❑DohmsTIC PRIVATE *GRAVEL PACKISIZE_ WELL CASING TYPE ! <br /> - WELL CASING DIA Az <br /> ❑PUBLIC/MUNICIPAL ❑DRIVENROUT SEAL DEPTH SZJ <br /> 24 HR N OTI ' SPECIFICATION <br /> ❑MONITORING <br /> 0ATT NR EQ U E S T E D OTHER GROUT BRAND NAME <br /> ONIFOR ALL GROUTSEALPUMPED: <br /> INSPECTIC7NS arES ❑xo <br /> 13CHRISTY BOX 13 STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES 0*NO <br /> APPROXIMATE WELL DEPTH n r7S 1 <br /> PROPOSED CONSTRUCTION/DRILLING METHOD:MUD ROTARY_AIR ROTARYY <br /> V AUGER CABLE R (1 �iIII <br /> I HEREBY CERTIFY THAT I HAVE <br /> PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE INqC�O ANCE WITH-SAN <br /> SOAQUINCO ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, ; <br /> ��1, <br /> 0 <br /> SIGNED: _.-.1 SAN C`QUiN COUN i <br /> u cr <br /> TITLE: /C,C <br /> DATE: vZ- <br /> W� 1f� Q -Sf•-'sl•f f/y. y�q,' d�..lY+ O-r-M r?' �\ <br /> � t <br /> t<• <br /> C <br /> 1 <br /> H <br /> t <br /> 1 <br /> DEPARTME USE ONLY <br /> 'ct <br /> Application Accepted By C Date "� <br /> �.-. � p Area <br /> Grout Inspection By r ate )/Pump Inspected 13 A.r_�1 <br /> � Date <br /> Destruction Inspection By <br /> /� Date <br /> COMMENTS: <br /> PE SC AMOUNT RECEIVED DATE PE T# <br /> CODES to INFO REI.IITTED H BY <br /> IDle <br /> v,< '� �Wau <br /> 3b3 016 ST7�-` Gc� <br />