Laserfiche WebLink
WELL/PUNIP PERMIT <br /> SAN JOAQUIN CauAITY ENVIRONMENTAL HEALTH DEPARTME6IT 13nd EAST HAZELTON AVENUE-STOCKT:)N CA 35205-7232 (209)468-3420 <br /> N0N-REFUI•IDAaLE21PE``R�IIT yINMN.sjgoY.OrG/9hd -EXPIRES 'I YEAR FROM DATE ISSUED <br /> +Joe AocP=a; y�`,J M bl ca>P t 1-1 1/� Clrr'_:P I i.�l 1 ra 1 1 <br /> V- ! 'tom'.S�OY _j!-0- _�''\ 1t�0_ I'a <br /> ,CRoss STREE-. � APN � V- PARCELSIZ°rO�.LAtJC UsE APPLICATION# <br /> (` �p 1' p <br /> IGvjNER NAME t (':,Lu S'�`.':�1� r D io`��';j STT 63(— PHONE P <br /> Iii'J I I <br /> TOWNER ADDRESS _`. 10,1S(� L �( �� )1 • I l CITYISTATE;ZIP Trul.� I/` \1 J q{;31 i� i <br /> CONTRACTOR V V^�2 Vr I�1t n �/ PHO1NE -(201)1)CSS IO� 7 -FO 0 <br /> CONTRACTOR ADDRESS 1 V 1I1b''U ur,,�F IDY-. CITYISTATEIZIP &--Ll T GQ�I/I_ 1?J(,:�;z, Z <br /> SUBCONTRACTORICONSULTANTf�.``A.(,C �''`i-I.Lr•�JI 'JJ�VU"-"! PHONE <br /> SUBCONTRACTORICONSULTANT ADDRESS A,)iV LrL�'�'� r�l P'�ICITYISTATE/jp Peer- Ste- 101 <br /> LICENSE 'V r.-57 C-61 .-D-09 =Other �J NUMBER 0 E/•v EXPIRATION DATE !/&6 20 <br /> Y `••' <br /> BILLING PARTY: G OWNER _CONTRACTOR SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING:_General Nlineral/Coliform Bacteria(4391) Dibromochloropropane(4392) Arsenic(4393) <br /> INTEt•IOEO USE _DomestictPrivate -Irrigation/Agdculturel Z Industrial r Water Quality Monitoring - oil Sampling/Characterization <br /> Public Water System <br /> If diffareat from Owner: water: 1 <br /> A <br /> TYPE OF WORK _New Well •_Replacement Well -U Perm I-t-( '0 r t\JC n <br /> Monitoring Welksl #.,f weIIS �S N 5 <br /> Out-Of-ServicePumWell _Q V((/ )Y ,r n 1n v� <br /> New Pum •_Pump Replacement =P `^n/UI t(V�,�,, 1 <br /> WELL CONSTRUCTION <br /> Drilling Method 7 Mud Rotary Air Rotary V"uger <br /> Proposed Well Depth_L]_ft Excavation_ j� �Q� S YJ n diameter <br /> Conductor Casing in diameter I L <br /> Well Casing Diameter_in Thickness/GaugeIASTM S, <br /> Grout Seal Depth • l 5 It '±Teat Cement 19- Qn'� �,d w D I� 7 gal water <br /> =Bentonite(20%solids) =Other <br /> _.••_•�^a D,,nn,d Free Fall e'Othar r <br /> to� t�(z ���nu� �z0 <br /> e Pipe <br /> �� _ (L��'(��n,4.e� .eek 4-bWa� <br /> tI y !TH SAN <br /> RI v 1`.Q V �,Y C!11 1ENSE IS ALL <br /> i <br /> I JLI <br /> L I I I I <br /> i <br /> 771 <br /> Ur 4 <br /> I , <br /> (;7 <br /> yAT- <br /> J j I <br /> - I I <br /> I <br /> DEPARTMENT USE NLY -! <br /> Application Accepted By Z Date $ Area Employee IG# <br /> Grout Inspection By Date SPE AL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By Date Co9ycted Well De th ft <br /> COMMENTS IF <br /> 'Fs l� ?.7 _L�'" 4 �j �� �rl.�� I <br /> PE Sc Rec ' e Check#/ Amount Date PermiU I Invoice# Well ID# <br /> Codes Into CLasbj f Remi!Td Service Request# <br /> 3LA S-'O U <br /> I <br />