Laserfiche WebLink
#1s24 <br /> WELL/PUMP PERMIT pump <br /> SAN IOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS 13436 N. 1110=10n Road APN 055- 130 - 01 <br /> CITYrm Lodi 95242 PARCEL SIZE - 41 <br /> OWNER NAME II1a ..L1RaJ1Ch Dairy � �„rt ADDRESS <br /> 13436 N. Thornton Roar; <br /> crry/zlP, Lodi 95242 PHONE P�9-5225 <br /> COMRACTOR_�elta Stockton PIIIIFD ADDRESS 646 S. California Street <br /> Crryam� Stockton 95203 466-9625 C57 L1cENSE# _EXP DATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X__ Y TOWNSHIP, RANGE_SECTION_ <br /> TYPEOF WELL: ❑ NEN WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL#_ <br /> TYPE OF PUMP: ❑ NEW (YREPAIR H.P. 5 DEPTH PUMP SET 63 FT" FIRST WATER LEVEL 30 <br /> ❑OUT-0F-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> BYfENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> �I INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIACONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELL CASING DIA W <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIRCA71ON 41 <br /> w <br /> ATnON/AG OTHER GROUT BRAND NAME S1 <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO z <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL.DEPTH 851 <br /> PROPOSED CONSTRUCTION/DMLLING 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 Z_ <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY C-57 LICENSE IS CURRENT 1 <br /> AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S O <br /> COMPENSATION LAWS. <br /> MINIMUM 24 IIOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS 7 <br /> SIGNED TME CI)O DATE 514 02 <br /> r <br /> AM j1d.0 <br /> d <br /> 'd <br /> i <br /> r. <br /> i <br /> /Q DEPARTMENT USEONLY <br /> {� ,�f� <br /> —�V�Q Date 7 �"-2 Atp 2fZ _EMPm#!"�� <br /> Application Accepted By� � 7 <br /> z 34L <br /> Grout Inspection By __ Date PumP Inspected By <br /> Destruction Inspection By (' Date <br /> COMMENTS: �'Z�l tJE6J.S To N�ATM rPNG WtS� .mr�� <br /> PE SC AMOUNT RECEIVED DATE PER MIT/SERVICEREQUEST# INVOICE# WELL ID# <br /> CODES INFO REMITTED CASH I BY <br /> 3 <br /> 050 90 �i� �-tz� 5 �c� R owlqgtUP � <br />