Laserfiche WebLink
WE'LL/PUMP PERMIT <br />SAN JOAQUIN (`AUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br />l _yu t <br />304 E. WEBER `VE, THIRD 17,CX1R STOCKTON CA 95202 (2.09) 468-3420W <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 1 ,Z4 ] J: t3,,:Yi d T a ,�` 5 �i, APN A GJ -e,dcJ <br />CTY/ZIP _ _. PARCEL SIZE—q)�Q!�G_ <br />OWNER NAME _ - ADDRESS /-�v <br />CM'/ZIP PHONE <br />CONTRAL`I'ORZ?,19T_L�7 , L -L 1J!Lr e2,C . :-AU e _ADDRESS 7y 11J <br />CI'I-Y/Z[P- - PHONEj.y -7 t---) -cam.)y.7 C-57 LfCENSE# G X33 A,? i EXP DATE1411/lw <br />GEOGRAPHICAL INMRMA'1'InN: COORDINATES X V TOWNSHIP IV.f RANGE Le_ SECTION L, <br />TYPE OF WELL: X3 NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL #____ ❑ OTHER <br />INSTALLATION: ❑ WbLL SYSTEM REPAIR D CROSS -CONNECT REPAIR D VAPOR EXTRAMON WELL # <br />TYPE OF PUMP: ❑ NEW ❑ REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br />❑ OUT -OF -SERVICE WELL O GEOTECHNICAL # ❑ SOIL BORING O DESTRUCCIlON: <br />ITiTENDED USETYPE OF WELL CONSTRU("I'ICIN SPTCIFfCATION <br />❑ INDUSTRIAL ❑ OPEN BOTTOM WELL EXCAVATION DIAria? CONDUCTOR CASING DIA <br />❑ DOMESTIC PRIVATE IS GRAVEL PACK/SIZE-:/ WELL CASING TYPE cd/2c! P, WELL CASING DIA ice, " <br />0PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH c�G.aC:' SPECRCATION rs/�e' ori <br />e erre.✓ r <br />JS IRRIGATION/AG OTHER GROUT BRAND NAME <br />❑ MONITORING GROUT SEAL PUMPED: IH YES ❑ NO <br />❑ CHRISTY BOX ❑ STOVE PIPE CONCRETE PEDESTAL BY DRILLER ❑ YFS Ed NO <br />APPROXIMATE WELLDEPTH <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THF. WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE, LAWS, AND RUI"FS AND REGULATIONS. I ALSO CERTIFY THAT MY C-57 LICENSE IS CURRENT <br />AND ACTIVE WITII TILE CALIFORNL4, CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br />COMPENSATION LAWS. <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRLll FOR INSPECTIONS <br />(� <br />51CsNED `�''_, /t. t��'_; - .,e Ire,, elm 42A ez,.4-4 Tfi7._E DATE /,r�A,,a <br />,; <br />ly El <br />JAW a 2 <br />�% <br />DEPART U <br />Application Accepted By r L' � Date `� �Arra� � `� __EMPMt # <br />Gaut Inspection By % 1`9 -4 mp Inspected By Date <br />Deuruction Inspection By Date <br />COMMENTS: <br />PE <br />SC <br />AMOUNT <br />CH1 t RECEIVED <br />DATE <br />PERMIT/ 'T #W VOICE # <br />WELL D# <br />CODF,S <br />INFO <br />REMITTED <br />CASH BY <br />MD <br />G <br />y <br />�, <br />