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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 /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f �` <br /> JOB`ADDRESS 1 �`C �l tr'-+'l APN 196! -ZO <br /> CITYII,.IP PARCEL SIZE '�Z hCy <br /> OWNER NAME i I `C�� ADDRESS q ' �1� 1590[0I�I 7-1( I�Jj' moi'NC <br /> CITYIZIP_ 1�_ �rt J Z 6 PHONEOY_) T 1 - OOO <br /> _ '1703 <br /> CONTRACTOR F7.!!-7L- `- _ADDRESS T 70 __`Z — <br /> CITYIZ➢P f IOC PHONE f 0 - O C-57 LICENS - 703 EXP DATE I C <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. MST WATER LEVEL <br /> 12- 70 Z5`t <br /> ❑OUT-OFWELL ❑GEOTECHNICAL#�� )(SOIL BORING 41 ED 16.5 ❑DESTRUCTION: <br /> IMNUED USE TYPE OF WELL CONSTRUCTION SPECIFICATION- <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DTA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZI; WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVE14 GROUT SEAL DEPTH SPECtFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAM � <br /> 13 MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> O CHRISTY BOX ❑ f STOVEPIPE CONCRETE PEDESTAL BY DRILLER: 13YES 13 NO <br /> APPROXIMATE WELL DEP'I'H1 S W —ZS I <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER-9—CABLE OTHER <br /> I HEREBY CERTHT 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 C NTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSXTION LAWS. <br /> OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNLD TfI7JE 4 ATEf " <br /> ■ <br /> 7 <br /> V11-TNII <br /> 10, <br /> J� <br /> AN JFr 3U1 V; ��UN <br /> L A <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area 21 EMPID# <br /> Grout Inspection by to Pump Inspected By ___pate <br /> Destruction Ins tion By Date � <br /> COMMENTS: <br /> FIE Sc AMOUNT CCHESW RECEIVED DATE INVOICE# WELL ID# <br /> CODES INFO REMITTED H BY <br /> '43?2 l 2,30-s X39, 5�2oao2R 3 8�- O Z:"Nqz 1 <br /> mal I tt97JL1&F- 3 q 23 2 Llrr: <br />