FIELD DOCUMENTS - Laserfiche WebLink

Home Browse Search

WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL BEALTH DIVISION 304 E.WEBER AVE., STOCKTON CA 45202 (209)468-3420 26�- 110-3 )- NON-REFUNDA�BLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 105 ADDRESS � � C/ I A//CO/o PARCEL SIZFlAPN-L!& /_��o��'t�Q� CITYfZIP OWNER NAME�Q,37&d G!�L� rte. ADDRESS CITY2H'__ � PHONE d + d CONTRACTOR. D I/ ADDRESS ZI CITY/ZIP C �1 FHONF z9 Cq !� f' L�tt .� GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE`� SECTION << TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# OTHER INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR Cl VAPOR EXTRACTION WELL of TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL Mr ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# MOIL BORING � OrDESTRUCTION: INTENDED USE TYPE OF SLI CONSTRUCTIONSPECIF[CATiONi ❑INDUSTRIAL G�/—t u j ❑OPEN BOTCOM WELL EXCAVATION PIA CONDUCTOR CASING DIA D ❑DOMESTIC PRIVATE ❑GRAVEL PACVJSIZE WELL CASING TYPE WELL CASING DIA n ❑PUBLICIMUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION ❑IRRIGATION/AG OTHER GROUT BRAND NAME ❑MONITORING 24 HR +` �f GROUT SEAL PUMPED: O YES ❑NO R E U ❑CHRISTY BOX ❑STOVEPIPE CONCRETE PEDESTAL 13Y DRILLER: ❑YES ❑NO APPROXIMATE WE DEPTH +_ �+'� � 5o�/**/y / S � M PROPOSED CONSTRUCHON/DRIL G ETHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER - I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE NE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDIANCES,STATE LAWS,AND RULES ANI;REGUL ATIONS OF SAN JOAQUIN COUNTY. SIGNED: �J / TITLE: DATE:_ / DEPARTMENT USE ONLY Application Accepted By Grout Inspection By Date Pump Inspected By Date- Destruction Inspection By i Date COMMENTS: ' ''�� :? l S= i Gil -1 \ li) t .'v4 ( V\-5 ' t-" ' TE SC AMOUNT CHECK#I/ RECEIVED DATE PERMIT/SERVICE REQUFST# WELL ID# CODES INFO REMITTED CASH BY gaol S5 i14� t 3�� ct x-53 se o