Laserfiche WebLink
WELI TMP PERMIT <br /> SAN JOAQUIN, NTY PUBLIC HEA. SERVICES ENVIRONMENTA..-..EALTH DIVISION <br /> • 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 <br /> y A/! NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> /� <br /> JOIJ ADDRESS- J /" y l AIN (;S j (1 G-J7 <br /> �� ) } <br /> CITY/ZIP -+�� 'V` PARCEL SIZE— <br /> OWNER NAME- <br /> IZEOWNERNAMME- /�1 + Aoj '_'C ADDRESS IJ' <br /> CITY21P 'TyC `�'U �SlL !` PHONE <br /> C0NTRACTO <br /> CR //!le�eZ ADDRESS <br /> CITYlLIP J-/mac4va� PHONETf&nEk/-7 C-57 LICENSEu�)l/3EXP DATP� �j�,, <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y_TOWNSIIIP_ RANGE_SECTION <br /> TYPE OF WELL: ❑�N—EW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL i1 ❑OTHER <br /> INSTALLATION: G WELLSYSTEM�REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# �I <br /> TYPE OF PUMP: ❑ NEW B REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL &/17 <br /> ❑OUT-OF-SCRVICE WELL ❑GEOTECI INICAL rl ❑SOIL IIOI(ING ❑DESTRUCTION: <br /> `tel i <br /> INTI?NDED USI+. TYPE..OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVELPACK/SIZE WELL CASING TYPE WELL CASING DIA <1 <br /> ❑PUBLICIMUNICIPAL ❑DRIVEN GROUTSEALDEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME C> <br /> n <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES O NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO z <br /> APPROXIMATE WELLDEPI'H 146) <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 WITII TILE 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 /> SIGNED J•�� TITLE... <br /> i <br /> n, <br /> I <br /> DEPARTMENT USE USE ONLY <br /> Application Accepted By !7 "` J"� Date U (! Area I( EMPIDM SI� �- <br /> Grout Inspection By Datc Pump Inspected By� Date /-'2 3 <br /> Destruction Inspection By Datc <br /> COMMENTS: <br /> PE SC AMOUNT HECK RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WE•LLID# <br /> CODES INFO REMITTED BY <br /> ;5\; 05 �,5 D O 0 D /2003%S� l <br /> I <br />