Laserfiche WebLink
WELL/PUMP PERMIT <br /> JOAQU;.v COUNTY PUBLIC HEALTH SERVICES ENVIRONMEN I, '•HEALTH DIVISION <br /> i `/ 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 <br /> w NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED P U M <br /> JOB 4DDRESS r, S Z Sdy <br /> PARCEL SIZE/APNII n Qt_ <br /> a,012CA(0 uG CITY/ZIP I"Iy�•CG� . C Pt SM 3�, <br /> OWNER NAME �l�Vrt�Dt ADDRESS _Q/10 p c�car <br /> CITY/ZIP�� n_CA "1�3D P PHONE 1.7i 09\J lj �I,_� 4 O <br /> CONTRACTOR V t W by n � <br /> ADDRESS�n `f/T ��•'.t <br /> CITY/ZIP PHONE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X–ty—k Y N A TOWNSHIP SIA RANGE!A-SECTION A) A4 <br /> TYPE OF WELL: ❑ NEW WELL 13Mw 3 REPLACEMENT WELL MONITORING WELL# M W^Z ❑OTHER <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 /> NaT,kPPuc�f�� <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA I I I N . CONDUCTOR CASING DIA N�Q <br /> ❑DOMESTIC PRIVATE GRAVEL PACK/SIZE ND-3 WELL CASING TYPE PVC-1 WELL CASING DIA I N-I•- <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN D GROUT SEAL DEPTH 10 T l SPECIFICATION'5X�a <br /> ❑IRRIGATION/AG 24 HR N OTI C EOTHER GROUT BRAND NAME m&y. �D,V bee\ Lo IIte-, <br /> AMONITORING R E Q U E STE lD GROUT SEAL PUMPED: 11 Ea NO <br /> FOR ALL <br /> CONCRETE PEDESTAL BY DRILLER: ES ❑NO CHRISTY BOX ❑STOVE PIPECY <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY 7�K AUGER k' 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 ORDIANCES,STATE LAWS ND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> i <br /> SIGNED: M <br /> TITLE;} SSaC�G4'p &qf au l� � 11r- , DATE:�Q�i2/W <br /> i. I CMM p <br /> R01M BM IB ROAD VwW. <br /> i 1 ' :o6, <br /> smc, i IN•A►PRGX.1660 rT <br /> SGIACL "SGS <br /> ""ADOO luv <br /> �•�10 I°c t O OIS07�IBOOIR . •,,,ate' <br /> 1G]13 Q <br /> 14 L vCt/C[ LOVLUCC ROAD <br /> M .� <br /> ROAo t R ol:mueLalR <br /> L C <br /> SHARPE t. g <br /> GL <br /> DEPOTO EXISTING YELL(STATE WELL NN <br /> DEPOT i � t <br /> o - <br /> I <br /> aouiRea Ro BN Is, I 2 <br /> .M WT OIf07c19101N <br /> N G <br /> 'MiIW-3 <br /> m SITE t s <br /> O•o <br /> 04064z"m11 <br /> i PROPOI M <br /> W.B 2_ + . <br /> _LVKMA -r MONITO RING <br /> PLANT flrE'M W-4 WELL ( YP.) <br /> ; I <br /> W.B. <br /> MW-2 0 <br /> i MW-1 <br /> • •• , ~ <br /> 011-Aim 11Y1C.1\1 U GVl LI( G D <br /> Application Accepted By �j� Date to 13'OCA Area <br /> Grout Inspection By Date �t.,Pump Inspected By Date <br /> Destruction Inspection By Date <br /> . COMMENTS: SSC.. W616-t b 5ECx-ioN 4.-13. 4 — Do koT ExLGM <br /> 6g:g f�E)';:T0wtr& " \)a c6'ht MT c o r <br /> PE SC AMOUNT CHECK#/ RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# <br /> CODES INFO REMITTED CASH Y <br /> �� t1 a,-?Dol <br />