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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION �- <br /> 304 E.WEBER AVE,THIRD FLOOR STOC-KTON CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED is9;aw! - <br /> /} � lam[f�� �-tea' <br /> ]OB ADDRESS V,EvAPN <br /> CITYIZIP PARCEL SIZE ZUe! A f"M,&— <br /> OWNER NAME_ ESSI �Ia 1 <br /> CITY/ZIP - i�/�j,�vsv� 7 Y/8 PHONE Z(6�2 g1� '�"I 69 <br /> CONTRACTOR— <br /> / / ke � _eWc ADDRES2 <br /> CITY/ZZIP 'c*"2 PHONE S�41��33- C-57 LICENSE#rOZ,66,'F EXP DATEA'OK <br /> GEOGRAPHICAL INFORMATION: COORDINATES X— Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# A!�iJ f _ r-?THE <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET PI: FIRST WATER LEVEL <br /> 13Q,OUT-OF-SERVICE WELL KGOPTECHNICAL# CI r)ESTRUCTION: �' <br /> RaENDED Uff TY�LL CONSTRUCTION SPErI) ICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DI.A-:±S� CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACKl�E WELL CASING TYPE A111f WELL CASING DIA oVA <br /> ❑PUBLIC!MUNICIPAL ❑DRIVEkr1 ��-;f:-f%';-" �' '' l' = LJ GROUT SEAL DEPTH �� � SPECIFICAATIJON ) <br /> 13IRRIGATION/AG d O OTHER GROUT BRAND NAME it o"-2 -G�I/C—,�/eyr- <br /> 13MONITORING GROUT SEAL PUMPED: 13YES 960 <br /> r 4VVf,�viV:;u 1_ iriFhIJfi // <br /> ❑CHRISTY BOE[ 13 STOVE PSE R L .,4�jT w F R�±I r-ES CONCRETE PEDESTAL BY DRILLER: 13 YES fdNO <br /> APPROXIMATE WELL DEPTH - ZC} <br /> PROPOSED CONSTRUCTION/DRILLING 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 <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY C-57 LICENSE IS CURRENT <br /> AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> j ``--'' COMPENSATION LAWS. <br /> Ia M1 I 24 HA71_JR ADVANCE NOTICE REQUIR D F R INSPE TIO I �J <br /> SIGNED TITLLC. , DATE <br /> IwPl <br /> W! <br /> i <br /> ALL <br /> ,4 U TY (� <br /> UB ICH hl ?SL NIC_S - <br /> IF <br /> DEPARTMETqT USE ONLY1A1 <br /> Application Accepted!By L s �` Datc Area EMPID#� <br /> Grout Inspection by ateZdLm�mp Inspected By —Date <br /> Des FN,,vvf, <br /> Inspection By Date <br /> CSTzSY47--: <br /> `" GL r . <br /> PE SC AMOUNT CHEC RECEIVED DATE P MlTlSERVICEREQUEST# INVOICE# WELL <br /> CODES INFO REMITTED CASH BY <br />