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" _. WELL/PUMP PERMIT �- <br /> SANlOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE,THIRD FLOOR.STOCKTON CA 95202 (209)468-3 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM PATE ISSUE <br /> [cn <br /> ADDRESS <br /> APN. <br /> Y2IP. L1 v i <br /> PARCEL SIZE <br /> ER NAM <br /> r ADDRESS <br /> /ZI1,. �`d PHONETRACTOR ADDRESSfLIP_ PHONE _� <br /> C-57 LICENSE# EXP DATE <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 <br /> .0 VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR ,H.P. DEPTH PUMP SET <br /> FT. FIRST WATER LEVEL <br /> OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BOR <br /> ING ❑DESTRUCTION: <br /> I`NTENDEI)USE TYPE OF WELL CQNSTRUCTION SPE IFI AT[ <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACKISIZE WELL CASING TYPE {�� WELL CASING DIA-- <br /> ❑PUBLICIMUNICIPAL ❑DRIVEN GROUTSEALDEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> 11 MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRIST)'BOX Q STOVE PIPE <br /> CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPTH 1- <br /> PROPOSED <br /> PROPOSED CONSTRUCTION/DRiLLING,METHQD: ,MUD ROTARY AIR ROTARY AUGER, CABLE_.OTHER, <br /> I HERE0Y CERTIFY TIIAT I IIAVE PREPARED THIS APPLICATION AND TIIAT THE WORK WILL BE DONE IN ACCORDANCE WITII SAN,` <br /> 30AQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO,CERTIFY THAT MY C-57 LICENSE IS CURRENT <br /> AND ACTRV.E WITII THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND TIIAT I AM IN COMPLIANCE WITII ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> MINIMUM 24 110 ADVANCE,NOTICE REQUIRED FOR INSPEICTIONS <br /> SIGNED 1L3Z G� f Trru-� F'/f C'�r ..DATF f\ <br /> �1 } <br /> 1; I I Uv <br /> "tt, Ilfl I:II <br /> DRTMENT tSE ONLY <br /> �' =�v ji''��' Arca f,.� �EMfT— C7_�j <br /> -. M. :. Applicatinr.Acccptccl By' Dalc 'ID# <br /> Grout Inspection fay Date Pump Inspected By Date <br /> -- <br /> Date <br /> 44%i neiiorn Inspecfitm - Dalc <br /> COMMf:N'1•S:_l.�s�r�.>�•,���..�.�.�..G�#:=��Y/�_��"Y��J.�+�� ff/��-G��..L'�.%�cr_/���,��_.=S'�-.<.�.>'�'-'�,�.�-._ <br /> III Sc' AM04 TNT 711:x. RFA7VIVED DATE ITRSIITISERVICE REQUEST M INVOICE M WELL IDM <br /> Ill R,i� INK) RI'MMI ill .II fly <br />