Laserfiche WebLink
T WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIMS <br />304 E. WEBER AVE, THIRD FLOOR STOCKTON CA 95202 (209) 468-3420 <br />f <br />WELL <br />JOB ADDRESS J 5 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />APN q— 12-6 �� <br />C1TY(L1P w <br />� r `- r7 a j� + _ PARCEL SIZE <br />OWNL.RNAME V`5[tibL1W xkl l� 1 ADDRESS lrC�� l I-FCl/ �p_M� �rI ` <br />Clr /ZpB J-qC,k-+D vN HONE J -L Z -20 3 z_ <br />1 CONTRACTOR f j ADDRESS <br />��u � �Yf 111 ✓l /'�, [J� <br />PHONE C-57 LICENSE#3 T��rZ EXP DATE <br />Cz- d 1 <br />10 Cak- GW 0'11-7 4-n I-/- y_ -70 2� <br />GEOGRAPHICAL LNFORMATION: COORDINATES X Y TOWNSHIP_ RANGE _ SECTION <br />TYPE OF WELL: ElNEW WELL 13 REPLACEMENTWELL ElI'T <br />MONI'T'ORING WELL# _ ❑ OTHER <br />INSTALLATION: O WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# <br />TYPE OF PUMP; ❑ NEW ❑ REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br />ROUT -0F -SERVICE WELL 13GEOTECHNICAL # ❑ SOIL BORING ❑ DESTRUCTION: <br />TFENDED USE TYPE OF WELL CONSTRUCTIONS EC1FI ATION <br />❑ INDUSTRIAL ❑ OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br />❑ DOMESTIC PRIVATE ❑ GRAVEL PACK/SIZE WELL CASING TYPE WELLCASING DIA <br />❑PUBLIC(MUNFCIPAL El DRIVEN GROUTSEALDEPTH SPECIFICATION <br />❑ IRRIGATION/AG OTHER GROUT BRAND NAME <br />❑ MONITORING GROUT SEAL PUMPED: ❑ YES ❑ NO <br />❑ CHRISTY BOX ❑ STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑ YES ❑ NO <br />APPROXIMATE WELL DEPTH <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY C-57 LICENSE 1S CURRENT <br />AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br />COMPF.NS ATION LAWS. <br />MINI UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED L <br />TITLE— DATES j <br />4E <br />n <br />I - <br />- I <br />a <br />j! U <br />- I <br />i <br />DEPARTMENT USE ONLY <br />Application Accepted By tei�� q,ea EMPIDft <br />Grout Inspection By <br />Date Pump Inspected By Dale <br />Desttucliam Inspection B _ _ Date _ <br />V COMMENTS;_ I I LQ'T C 00 2-o6 <br />PE SC AMOUNT' CHECK#/ RISC ED DA PERMIT/SERVI EREQUEST* ID# <br />S` CODES INFO REAlITIED By TNG ICE# WEU. <br />a <br />t.L4. .0-� �.l,G'l Crtl� i7 -G c. tic: 2t`O}� C. rril.ecCr ..t <br />