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WELL/PUMP PERMIT - <br /> SAN JOAQUIN,,wJNTY PUBLIC HEALTH SERVICES ENVIRONMEN.r 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 <br /> JOB ADDRESS 9/g 3e9 �' �/ �P r�C�� APN 176 <br /> CITY/ZIP�/�G �L'1 -__PARCEL SIZE <br /> OWNER NAME AY1� G" 5 � Y"r�� r ADDRESS_�� <br /> CITY/ZIP 15 o G 7 Tti'yJ PHONE <br /> CONTRACTOR LJ�s/ 4 7/�*t Ll,Q— ADDRESS <br /> CITY/ZB' rQa m/%40 GO r`/0'��( PHONE rr K-37� C-57 LICENSE#f Ole_ EXP DATE <br /> 37,710 i2/_,g7yz <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# THER <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 /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION D `J I� CONDUCTOR CASING DIAJOV <br /> ❑DOMESTIC PRIVATERAVEL PACK/SIZE ©.2O WELL <br /> SCG L CASING WELL CASING DIA ? / <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES SCJ NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPTH 5:0/ <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER K _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 /> M IMUM 24 HOUR AIGANCE NOTICE REQUIRED FOR INSPECTIONS <br /> [A .1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 <br /> `/ ,,�/ DEPARTMENT USE ONLY n <br /> Application Accepted By gk4- �C Date � Area/ 0Z—' EMPHO 9f 7 <br /> Grout Inspection By �-a Date b3 Pump Inspected By Date <br /> Destruction Inspection By DatateL <br /> COMMENTS:_ypf `�•eyl'�- �* /� c ��3U S, F� �A .C�O 7I - <br /> PE SC AMOUNT CH K#/ RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL ID# <br /> CODES INFO REMITTED CA BY <br /> 16- d3 5)2oo 3Z�_A4 <br />