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vv hjuu r u ivir Y vlf 1 <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.IWR AVE,THIRD FLOOR STOCKTON CA 95202 (2268-3420 <br /> D oT V Tj`la. NON-REFUNDABLE PERMFF EXPIRES 1 YEAR/FROM DA SUED <br /> JOB ADDRESS ri'E0."k(nn oL •" COu�!l j-�i R 0 ��i0 R+yl." 1 APNa <br /> CPFY/Zpp :jj�q 5�i-J� I PARCEL SIZE <br /> OWNER NAME CQ Il 13l ADDRESSRnns- <br /> CITY/ZB' - rmc� a 53'7 b PHONE <br /> CONTRACTOR ADDRESS 8'70 aVS Dr. 300 <br /> G Dr�U�'r4 7�Sh .nc . <br /> CITY/LB' �n(xOyvte {-o J 85833 PHONE A(lo"in-7q"c�.COG C-57 LICENSE# 5(b5 EXP DATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y_ TOWNSHIP-2 5 RANGE SS 6 SECTION�S <br /> TYPE OF WELL: BL 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 FF. FIRST WATER LEVEL b <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: Ll <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECITICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA 10" CONDUCTOR CASING DL4 <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE_ WELL CASING TYPE Sch 40 PUC WELL CASING DIA 4 0 <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUTSEALDEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> 2"MMONITORING GROUT SEAL PUMPED: GY4ES ❑NO <br /> 87CHRISTY BOX ❑STOVE PIPE p CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPTH V 0-0 >- S Ce. Qu0..CMPl\ <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY_AIR ROTARY_AUGER V�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 I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> '' ii"" nn MINIM M 24 HOUR ADVANCE NOTICE REQUIRED FOR <br /> �IyN�S,,,PEEC�T�Iml <br /> SIGNED_ —L TITLE u�J r '-""—d" <br /> i <br /> i <br /> DEPARTMENT USE ONLY O <br /> Application Accepted By Z Date Area EMPID# <br /> Grout Inspection By ^^-o' Date3 Pomp Inspected By Date <br /> Desw —Date <br /> Inspection By <br /> COMMENTS: m W S �� <br /> PAu) n <br /> PE SC AMOUNT CHECK#/ RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL ID# N <br /> CODES INFO REMITTED CASH BY <br /> b 10Z_ 0029032 <br />