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WELUPUMP 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 /> 7- NON RiDIM�BLE PERMIT EXPIRES I YEAR FROM DATE ISSUED rJ <br /> JOB ADDRESS J.L 6�r3 L"R APN Of <br /> CITY rLIP SrUG�rN <br /> L /��� L G <br /> PARCELS--IE �3 Oc^r C <br /> OWNER NAME ..b�.e_/� /t},T/c.W1 G1,LnDRESS_ ��7 �� �I L� 4 �-h <br /> CITY. (J.f —— <br /> PHONE <br /> CONTRACTOR_ ADDRESS <br /> CITY/ZIP PHONE C-57 LICENSE# EXP DATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y_ TOWNSHEP_ RANGE—SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR O CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL N <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET PC. FIRST WATER LEVEL <br /> )(OUT-OF-SERVICE WELL ❑OP.OTECHNICAL A ❑SOIL BORING _ ❑DESTRUCTION: <br /> INTINDED USE ME OF WE CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DSA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACKISIZE WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLICOAUNICIPAL ❑DRIVEN GROUT SEAL DEr`TH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX O STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL.DEPTH_ 120 _ <br /> PROPOSED CONSTRUCTIONmRILWG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER V1 <br /> ►HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COU INANCFS, LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY C-57 LICENSE IS CURRENT' <br /> AND TI CALIFO CO CTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> MI .IMUM 410 VANCE NOTICE REQUIRED FOR INSPECTIONS T <br /> S NED Tfl <br /> J <br /> iri k_4=1 <br /> ol <br /> LLLL <br /> Len <br /> LLLLLL <br /> i <br /> h L <br /> it <br /> DEPARTMENT USE ONLY 44 <br /> Applimfioc Accepted By• Date 1_Am Z, BMPW# <br /> Grout Inapxtioa By Date Pump Inspected By t 1`C� v�- �W <br /> Destructico Inspection By �7 / to <br /> COMMENTS: HR 4ure — �� ('-n/. 7 S /Y�Krn <br /> PE SC AMOUNT H C RECEIVED DATE ITJSERVICERBQU tt INVOICE WELL IDN <br /> CODES INFO RP.MII7ED CASH BY <br /> ?4/3 23b I <br />