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7' WELL/PUMP PERMIT <br /> SAN JOAQU CIN OUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH (+ <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED !1 <br /> JOB ADDRESS 4 4ye APN <br /> CITYIZIP PARCEL SIZE-----!—'—rR <br /> OWNER NAME /" ADDRESS 7 y IIA) LY `� <br /> CI7 Y/ZIP PHONE Cf�r <br /> CONTRACTOR ADDRESS <br /> CITy/ZIp `T' /V 5���J PHONE `7� I. C-57 LICENSE# Z5E3CP DATE L <br /> 10 <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> (� INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW Q REPAIR H.P. DEPTH PUMP SET Pf. FIRST WATER LEVEL <br /> El OUT-OF-SERVICE WELL ,EOTECHNICAL# ❑SOIL BORING 0 DESTRUCTION: <br /> rNTENDE12 USlv TYPE OF WELL CQNSTRUCTION SPECIFICATIO <br /> J\ ❑INDUSTRIAL ❑OPEN BOTTOM CQWI~XCAVATION I%F�_ CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELL CASING DIA <br /> k t1� <br /> D PUBLICIMUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATIONIAG OTHER"GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> �j 0 CHRISTY BOX . 13 STOVE PIPE r CONCRETE PEDESTAL BY.DRILLER: ❑YES ❑NO <br /> 1 APPROXIMATE MIM DEPTH 10 <br /> I PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> j� JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY C-57 LICENSE IS CURRENT <br /> AND ACTIVE WITH THE CALIF IA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> C 4 HOUR ADVANCE.NOTICE REQUIRED FQR INSPECTIONS <br /> SIGNED7/- TITLE_ S S <br /> C <br /> -44 <br /> 7 <br /> Z J <br /> i in <br /> k , y <br /> i <br /> 7— <br /> VDLM r <br /> DEPARTMENT USE ONLY- <br /> 67 <br /> r <br /> Application Accepted By Date -Area—2& EMP0#--!!;�� <br /> Grout Inspection 13 Date Pump Inspecte By Date <br /> Destruction Inspection By 7i � Date <br /> COMMENTS: <br /> i <br /> PB SC AMOUNT CHE RECEIVED DATE PERMft/SERVICE REQUEST# INVOICE# WELL ID# <br /> CODES INFO REMITTED CASH BY <br /> 'A 30 /adoZ 2-q '�� Wpop A3 <br /> 3 <br />