Laserfiche WebLink
WE' - PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC LTH SERVICES ENVIRONMtNTAL HEALTH DIVISION <br /> 304 E.WEBER AVE,THIk-.LDOR STOCKTON CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT/EXPIRES I YEAR FROM <br /> G DAAµI <br /> [JOB ADDRESS IAPSN$jJED�C <br /> S12g- 6b()-s:3 <br /> CITY/ZIP N. A PARCEL SIZE <br /> OWNER NAME TIM MsV=r7,030ADDRESS-XO Y-MLLL,�&. MJG- 94NiQ1,01CK,JIB. f-Q.FCX ��f <br /> CITY/ZIP S bCr-TW . CA g52-Q1 - N4+ PHONE f�ej) 94-C - (1203 <br /> CONTRACTOR PrTGH DII;TLL�C7 ADDRESS Irl Pr—f)1F_715 57TH <br /> CITY26P E- fP LO A LTO, CA q43 03 PHONE I/O C-57 LICENSE#7L-3-0 5-EXP DATE 2CS <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP 2/. RANGE 5E SECTION 3S <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL 71- MONITORING WELL# ]K {R 60 L 6%PDVG-5 <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 �tileAtA- X ❑DESTRUCTION: <br /> w� V7(�ra �J wi22 .��33�ta a-melhw_ <br /> INTENDED USE TYPE OF WELL CON51111 I'ION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIACONDUCTOR 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 6Murnd wa¢e� tuRe� GROUT SEAL PUMPED: AYES ❑NO <br /> IXCHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> / / <br /> APPROXIVIATE GRLDEPI'H t� �1J ^� / <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY V 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 /> INIMUM 24 IiOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED ^� TITLE MY A1!55 DATE C l6 <br /> If <br /> V. <br /> { }R <br /> . T <br /> �7; �� i C U i• &dl P,f R F sa_�t<4.T J /�'-.v,l�a1!I7 _ �i <br /> Inc toM'9i e. "_"_"�T`--��R(b'�'1� <br /> AIIRIOhlsR-1004NapiFhI C..l tlan, <br /> 11 <br /> 9 e 6 ~�t <br /> DEPARTMENT USE ONLY <br /> -74 <br /> Application Accepted By \ Date G Area EMPID# 7 �' <br /> Grout Inspection By , V Dat Pump Inspected By Date <br /> Destruction Inspection By Dale <br /> 11__ { r ' 1 V ntt. w i rte, <br /> COMMENTS: 2 17A�'t r\g5 1 h t=QC� 0T L4 l0 Dti� aU cD np IL4�. as •{i(C711t►1 G!S <br /> PE SC AMOUNT CHECK#/ RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL ID# <br /> CODES INFO REMITTED CASH BY <br />