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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 PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> J013 ADDRESS �� /� - .r���,-�T D r� APN O 0— 11 <br /> , <br /> CriTiZIP_ C;b[ � CG PARCEL SIZE 42 <br /> OWNER NAM `��f �{'�'� 1�t1 ADDRESS �I �1 /�J- Ia//�//✓��� C.� <br /> crry/zlP�SCK G'd a. _,.,, _.._..,...1_,S.r_ /;r. PHON 4k- Olfecy <br /> CONTRACTOR ADDRESS <br /> CI YIZIP PHONE C-57 LICENSE# EXP DATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALIAI ION: '❑WELL SYSTEM REPAIR ❑CROSS CgNNBCT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUNIP SET FF. FIRST WATER LEVEL <br /> OUT>� <br /> -OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING 13DESTRUCTION: <br /> INTENDED USE TYPE-OF_WELL CONSTRUCTION SPECIFICATIOLY <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELL CASING DIA--7/ <br /> a PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> E]IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SISAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX C7 STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> 'APPROXIMATE WELL DEPTH..• <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY TIIAT I RAVE PREPARED THIS APPLICATION AND THAT TIIE 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 WITII TIIE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND TIIAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> MINIMUM Za II(r ADVANCE:NOTICE REQUIRED ICOR INSPECTIONS � <br /> SIGNED TITLE 7t C.e S'efll C' —DA <br /> DATFr <br /> I <br /> /�, i\, <br /> ; 1 <br /> �L(A <br /> DEPARTMENT SE ONLY <br /> Application Acccpled By Date Arca Z Z EMPID# <br /> Gmul Inspection By Date Pump Inspected By Dalc <br /> 4et+ttuetion InspectiDalc d1/1QZ� <br /> COMME:NTS:_.11w�r���7�J�C]���G�VI��Yc�=v —���— <br /> t�'T , n' _ <br /> I'lt �l' AMl)1�f1T 71F[ RFA.LIN'11) DATE I'-R%IIT/SERVICE REQUEST K INVOICE N WELL ID# <br /> ift#11y MITI!' ) .N ItY p <br /> r Lift _��.. �`� , 4141103. s <br />