FIELD DOCUMENTS_FILE 2 - Laserfiche WebLink

Home Browse Search

WELL/PLJMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION -- 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 2 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED( i ' -1 i JOB ADDRESS I.I�./�� lA� i ) APN ll 1� `'-'1 Io -4Z CITY/ZIP ��" "'�� 7106m EL SIZE OWNER NAME DDRESS CI7 Y/ZIP PHONE I �� 'J CONTRACTt�11 L ADDRESS CITY/zip PHONE�-'==�"✓� ✓O(i'l./ C-57 LICENSE# EXP DATE I GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION TYPEOF WELL: 13NEW WELL 13REPLACEMENT WELL ❑ MONITORING WELL# g�HE �YYi INSTALLATION: ❑WELL SYSTEM REPAIR Q CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# �TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL UT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING DESTRUCTION: v/INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION ❑INDUSTRIAL OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA OMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELL CASING DIA ❑PUBLIC/MUNICIPAL +`DRIVEN GROUT SEAL DEPTH SPECIFICATION 13IRRIGATION/AG OTHER GROUT BRAND NAME ❑MONITORING GROUT SEAL PUMPED: XyES 13NO ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO APPROXIMATE WELL DEPTH_- PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY C-57 LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S COMPENSATION LAWS. MIN 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIG 6ii TITLE/�� DATE BENJAMIN HOLT DRIVE S�}� 0D 00 WASTE OIL TANK APPROXIMATE PROPERTY BOUNDARY fy�� MW-12 0 FORMER UNDERGROUND MW-90 Mw-5 STORAGE TANKS MW-3 STATION DISPENSER '6w-i BUILDING ISLANDS ; -/O MW-6 W O �• USTs \� KIOSK U p MW-10 / DISPENSER U " \' ISLANDS Q MW-4 O CL