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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)466-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED Crit g f <br /> • r <br /> JOB ADDRESS / / /9x A189 a am Ito <br /> CITYIZIP Z0,'_;6 PARCEL S / <br /> OWN ER NAM ��CC/�/Z. ADDRESS COP Q �} <br /> CITYIZIP Ll�� PHONE �� �� �/917 <br /> CONTRACTOR ADDRESS j <br /> CITYIZIP PHONE C-57 LICENSE# EXP DATE <br /> I <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION_ <br /> TYPE OF WELL: Q NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# THER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> fF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> DED USE TYPE OF WF,LL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLIC(MUNICIPAL .❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> 4 ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> k ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> f <br /> k APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTIONIDRI..LING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORD 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 /> MINIMU 24 "Ho.tjR AIW&NCE NOTICE REQUIRED FOR INSPECTIONS <br /> 5EGNED �/� Ii 17fiLE� 1 / DATE - <br /> Y11 LL <br /> I <br /> X <br /> LU.L <br /> I v, <br /> DEPAR NT USE ONLY <br /> *LAApplication-Accepted By_ z'�/l 1 [, Date 9 (14(()1 Area EMPUM ( <br /> _w <br /> Grout Inspection By_ , Date specte By / �.�.�� Date <br /> r✓u til� � <br /> Destruction Inspection By Date <br /> COMMENTS: e) A A AO a <br /> PE SC AMOUNT (-CHEC�W RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL 1D# <br /> COD INFO REMn`TED SH BY <br /> r. n� S � 1.,t.-,P _ -.7 4'i. I ��, �'.. ,. fl • '.`1r�.' "��..;\h�l 'l .f k �rh �• ./[-` ,,.. � ! 1/r r <br />