Laserfiche WebLink
WELL/PUMP PERMIT <br /> • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMF.N'TAL HEALTH DIVISION <br /> t 304 R.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 <br /> a <br /> t NON-REF"t DAIILE P RMI'1'E IRES I YEAR FROM DATE,ISSUED <br /> JOB ADDRESS —...--A PN. <br /> s--� <br /> C.ITY/zIP PARCE SI7.E_ _ <br /> OWNER NAME �LKx ADDRESS /�/_ wr i- <br /> CITY/zIP T" ___ _e _ PHONE—`X — <br /> CONTRACTOR;IVIS �1 f ADDRESS//'J4/466L—C . <br /> CITY/ZIP!T ►_[[1�� PIION t;57 LICENSF.#���F.XP DATE.2J223 <br /> GEOGRAPHICAL,INFORMATION: COORDINATES X Y. TOWNSHIP RANGE SECTION <br /> 0 I <br /> TYPE OF WELL: ❑ NF.W WELL C1 REPLACEMENT WELL ❑ MONITORING WELL#__ -�C7TETE1� 4--�I l L <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# — <br /> TYPE OF PUMP: ❑ NEW []REPAIR II.P. DEPTH PUMP SET IT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WILL ❑GEOTECHNICAL# _ ❑SOLI.BORING ❑DESTRUCTION: .. <br /> IIV7"F:M)F.D USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL 0 OPEN BOTTOM WELL EXCAVATION DIA��� CONDUCI"OR CASING DIA <br /> OMESTIC PRIVATE GRAVEL PACK/SIZP. WELL, CASING TYPE WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIF-ICA-1-I0N <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME�Q� <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ^0 <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES Qi!40 <br /> APPROXIMATE W EI.I.i7EPI H .-. 60 <br /> PROPOSED CONSTRUCTION/DRILLING METIiOD: MI.JD R(7CARY�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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> _ <br /> SIGNED t ,`\i/�rt DATF.� J�1-� <br /> � L TITLE-..._ _ .. <br /> I <br /> I <br /> 2U Rug <br /> All <br /> 1 — — <br /> EPARTMENT USE ONLY / <br /> Application Accepted By _ _Date-?r Arca Z! EMPID# <br /> Grout Inspection By _--Date __Pump Inspected By- _ _.- Date <br /> Destruction Inspection By _ .. Date- <br /> COMMENTS:-_ V�JQlGX K fin <br /> PE SC AMOUNT Cli C RECETVF.D DATE PERMIT/SERVICE REQUEST# INVOICE# WELL 1D# <br /> CODES INFO I REMCTTED CASH BY <br /> 67 A Z-01 ;-494 (CODala/oL S� 1J02 o9oAst� <br />