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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 PERM*T EXPIRES 1 YEAR FROM DATE ISSUED � <br /> JOB ADDRESS .2820 S, is s—,. APN �/l� <br /> j j' 0S� <br /> CIrymp ST-Oc-ac�N . ��ac� �,v` cxe S <br /> U��[ <br /> F{ PARCEL SIZE >�Iz�S <br /> OWNER NAME_L"CTT/A CHAN t{Z DRESS tab J( 1 I 1 <br /> CITY/LTP ST'0L*--mtJ PHONE <br /> CONTRACTOR 0 C I L A(JM2S-DfJ I ASS9l ADDRESS_ 2-2- N_ HDuSTDIV _N <br /> CITY/ZIP LOL>1 `152J`lifl PHONE 3b�7 -3'TO, <br /> C-57 LICENSE#6L400'4 EXP DATE 2a 3 <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y TOWNSHIP_ RANGE_SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# <br /> ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUhIP SET <br /> ,/ FT. FIRST WATER LEVEL <br /> (�J <br /> ❑OUT-OF-SERVICE WELL GEOTECHNICAL# ID Iy SOIL BORING <br /> r ❑DESTRUCTION: <br /> INTENDED TYPE OF WELL—� CONSTRUCTION SPR/'IFI.pTION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA <br /> CONDUCTOR CASING DW <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE <br /> WELL CASING TYPE WELL CASPIG DIA <br /> ❑PUBLICANUNTCPAL 13 DRIVEN <br /> GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME (�NOI*U';4i <br /> ❑MONITORING <br /> GROUT SEAL PUMPED: ❑❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELLDEPIN11%C IoPROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY_qIRROTARY_AUGERV CABLE_ OTHERI HEREBY CERTIFY THAT I HAVE PREPA RED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> LICENSE IS CURRENT <br /> AND <br /> JOAQUIN <br /> WITH THIN CALIFORNIA CONTRACTORS STATE LANCES,STATE LAWS,AND RULES ICENSE BOARD AND GULATIONS. I ATHAT I AM IN COMPLIANCE LSO CERTIFY THAT WITH ALL WORKMANCOMPENSATION LAWS. <br /> 11NIM11M 24 HOUR ADVANCE.NOTICEREQUIRGD FOR INSPF,CTIONS <br /> SIGNED TITLE / ( a^t6DATE <br /> l/1 <br /> P <br /> —r E <br /> TI <br /> DEPARTMENT USE ONLY <br /> Application Accepted B �� <br /> 2 sL7O 2 I <br /> Grout Inspection yDate�Pump Inspected By <br /> Daly <br /> Destruction Inspection By <br /> Date <br /> COMMENTS: <br /> PE SC AMOUNT HECK RECEIVED DATE PERMIT/SERVICE <br /> CODES lNPD REMHTED BY REQUEST# INVOICE# WELL <br />