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WELL/PUMP PERMIT <br /> [JSAN JOAQUQMUNTy PUBLIC HEALTH SERVICES ENVQ20NMENEALTH DIVISION <br /> 304 BWER AVE.THIRD FLOOR STOCKTON CA 95202 W 468-3420 <br /> aS� Z-�Z j NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED�p <br /> JOB ADDRESS 1-56n APN s"- 50ry <br /> crrrrz>PTvac v q 537 b <br /> PARCEL SIZE <br /> OWNER NAME& ADDRESS_ 132.+ 0. /102 <br /> CrrY2IP —Crar q / R S3 to PHONE <br /> CONTRACTOR--Q-L5 rb r>,�\or\ ADDRESS 12:10 Ca Uv <br /> C" .7[�.Tfn ,�„r..,.;nLn q 5 x33 PHONE_ 0%• 5 \l:cy d.,cl TtSkrsa7n c <br /> C-57 LICENSE#�I SS lbs EXP DATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y_ TOWNSHIP AS RANGE-5E SECTION aS <br /> TYPE OF WELL: M NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAB2 ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMPSET FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION V <br /> ❑INDUSTRIAL ❑OPEN BOTTOM ,V <br /> WELL EXCAVATION DIA 1D incN CONDUCTOR CASING DIA- <br /> 11 DOMESTIC <br /> IA_11DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE_ WELL CASING TYPE ?VC-Sc6ed a40 \\ <br /> WELL CASING DW y inch <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEL DEPTH <br /> SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> W'MONITORING <br /> GROUT SEL PUMPED: IVES 0N <br /> Ei"CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXBvIATE WELL DEPTH hp Ge, g 0.Ck\C <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY_AIR ROTARY_AUGER ✓ CABLE— OTHER ~ <br /> I HEREBY <br /> RTIFY THAT I <br /> VE <br /> PARED <br /> IS APPLICATION AND <br /> JOAQUIN COUNTY ORDINANCE STATE LAWS,AIND RULES AND REGULATIONS..II ALSO CERTIFY THAT MY C57WORK WILL BE DONE IN 0LICEN E IWITH <br /> 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 /> 1 fmu 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS Vr <br /> SIGNED /j�� <br /> TITLFj�/'��N V�DATE <br /> DEPARTMENT USE ONLY <br /> Application Accepted B/yI�/ Date �1/�n Areaa� EMPIDN <br /> Grout Inspection By ate3 6 Pump Inspected By Date <br /> Destruction Inspection By Date <br /> COMMENTS: //'( <br /> PE SC AMOUNT CHECK* RECEIVED DATE PERMrr/SERVICEREQUEST# INVOICE# ---WELL IID# <br /> CODES INFO REMITTED CASH BY <br /> -oa- <br />