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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 P RMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IIC�ss. S��'� �/ g - � �,�. <br /> JOB ADDRESS_- APN--(.{�3 r10-,�A <br /> CITYlZIP c`1 C 1 Z PARCEL SIZE <br /> OWNER NAME_` DAjjL___C' T0SV ADDRESS 0 S <br /> CITYIZIP z l 2 PHONE ( Q l 3/al <br /> CONTRACTOR Ni ADDRESS <br /> CITYlltp _ (.OD%� ZZ PHONE (�01 367' 37,Q)C-57 LICENSE# _EXPDATE,21�3 <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: ❑ NEW WELL 0 REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <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 WELLGEOTECHNICAL# 0 S01 BORING ❑DESTRUCTION: <br /> INT VYDED US,E TYPE OF WELL CONSTRUCTION PE C TION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA 4 <br /> 0 DOMESTIC PRIVATE ❑GRAVEL PACKISIZE WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATIONIAG OTHER GROUT BRAND NAME 0'c"I-0 til S <br /> ❑MONITORING GROUT SEAL PUMPED: ❑AYES ❑NO.�� G <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO U <br /> APPROXIMATE WELL DEPI'H--S,_I,n IS <br /> PROPOSED CONSTRUCTIONIDR[LLING 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 /> 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 /> MINIMUM 24 HOUR ApVANCE NOTICE REQUIRED FOR INSPECTIONS � i <br /> i <br /> SIGNET? �� TITLE DATE--a/11 <br /> 1 <br /> 1 <br /> noir.H High-7 Et <br /> 6toe .,rA <br /> 9S2I24336,u6 �� I <br /> y7A�ThV{f*-� �BOY( 1 <br /> A -NIT <br /> Dc <br /> to _- <br /> I <br /> AN JU <br /> PU 4V131 <br /> EN y <br /> EE n[M1l2 Rd EE M1 m <br /> LL <br /> DEPARTMENT USE ONLY <br /> Application Accepted Date d�" Area 2 EMPID# 1 � <br /> Grout Inspection By Date Pump Inspected By q Date <br /> Destruction Inspection By Dat ac-4 <br /> I � <br /> COMMENTS: -z� S ro 15 wit I, P#4Aj <br /> PE SC AMOUNT CH ! RECEIVED DATE PERMITJSERVICEREQUEST# INVOICE# WELL ID# <br /> CODES INFO REMITTED CASH BY <br /> 372 15-6 -7,30 F<0630V9 <br /> � �1 <br />