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Gj,o55kY0 - L4o2- 1 . 2-3o <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468.3420 <br /> �Q <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS � � WQy 1f I�'+r�a (� _ APN <br /> CITY/ZkT L-4c I � 1 �P /� ` _,`PARCEL SIZE <br /> OWNER N AME_(A� �IAtT 1' ADDRESS I� 5 ft)�LA0 0- . <br /> CITY/ZIPL � r P14ONB(Z0%� �, rb 7940 <br /> CONTRACT�OR��S50 60(. ADDRESS L1Z t-bL) �V"" t-IV I <br /> CTTY/ZIP '� _Z' PHONE SCO 34�b i C-57 LICENSE# _EXP DATE <br /> GEOGRAPHICAL INFORMATION:'COORDINATES X Y TOWNSHIP RANGE SECTIONN <br /> TYPE OF WELL: ClNEW WELL 11REPLACEMENT WELL ❑ MONITORING WELL# iA 07TIER " <br /> INSTALLATION: ❑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 /> C7 <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# OIL BORING _ ❑DESTRUCTION: <br /> INTENDED 1JSE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA � <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPT' WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DE£'CH SPECIFICATION <br /> ❑IRRIGATIONIAG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOLI ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPI7I _ <br /> PROPOSED CONSTRUCTIONMRILLING METHOD: MUD ROTARY AIR ROTARY AUGER -'O�l CABLE OTHER <br /> I MREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION ANTI THAT THE WORK WILL BE DONE INACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY CZ7 LICENSE IS CURRENT <br /> AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> NIMUM 24 HOUR ADVANCE.NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED 7I_m_E / F wuc—& DATE VL U Z <br /> I L� - -- <br /> t <br /> rQi w <br /> .baa <br /> M <br /> L <br /> I <br /> DEPARTMENT USE ONLY <br /> Application Accepted 0 A&A 11 Date a- � _Area (� EMPID# <br /> Grout Inspection 11- ate4j� Pump Inspected By Date <br /> Destruction Inspection By Date oe <br /> COMMENTS; <br /> PE C AMOUNT HE RECEIVED DATE PERMIT/SERVICE REQUEST# VOICEp WELL ID# <br /> CODES INFO REMITTED BY <br /> 4312. ISO 130 tJ �t 3 � -]0 �,qL4 �tl� <br />