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r W11LI,/PUMP PERMIT - <br /> SAN JOAQUIN COUN'T'Y PUBLIC IIEALTII SERVICES ENVIRONMEN'T'AL IWALT]I DIVISION <br /> r15 E ily„I y p$ 304 E.WEBLR AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 <br /> 15Sl :UNU�{ �UAks P?t[�111X IRHS {YNAtIHOM1)Ais�� /C� � _ 060 <br /> 6 f <br /> )OB ADD'. ' A PN <br /> 51IiO 11TY011- R(E_f)_9_j* <br /> L -- - <br /> OWNER NA 1.. > AI)I)ItEsti >7 � L — <br /> �wya } � —P[]ONE- <br /> CONTRA 0 <br /> ONECONTItACTO� � ADDRESS - ¢,/ l -�/�// _ <br /> �I'1'YlZII' �-PIIONE �/�1 C-57 LICENSER- L! 'EXP DATE,•! <br /> GFOGRA I'll[CAL INFORMA'T'ION: COORDINATES X Y TOWNSUIP RANGE SECTION <br /> tPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORINCi WELL# _❑O'llIER <br /> INSTAIA.ATJON: ❑WELL SYSTI-M REPAIR ❑CROSS-C'ONNECTREPAIR ' ❑VAPOR EXTRACTION WELL# <br /> 1' P.tJt,- - _f�{ li5CiI' _ j �T. FIRST WATER LL'VEI.— <br /> Ol1T-4-SERVICC W-LL ❑lCiEOTEC I JICA .� L7 SOIL El(]f�IfV 111)ESTR I KTHON; <br /> 11,14D1 D I)SE TYPE OF WELL CONS'1']tlJE7ION SPEXAFICATIQ <br /> INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE <br /> WELL CASING TYPE WELL CASING DIA <br /> PUITLIUMUNICIPAL ❑DRIVEN GROUT SEAL DEPT'Ii SPECIFICATION <br /> 0 IRRIGATION/AG OTHER GROUT BRAND NAME <br /> MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX 13 STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> ('PROXIMATE WELLDEI'I'II <br /> '�OI'OSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY ANGER CABLE ()TITER <br /> fNDACL HEREBY CERTIFY'THAT I IIAVV PREPARED'TIIIS APPI.ICA'J.ION AND'THATTHE WORK WILI,Ilk:DONE IN ACCORDANCE WITH SAN <br /> TlV ' <br /> OAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY C-57 LICENSE:IS(.UltRLN'L' <br /> 1'1'1'11'1'1[E CA1,11,'ORNIA CON'TItAC"TORS S'TA'TE LICENSE:IIOAltD AND'I'IIA'1'1 AAI IN COMI'I.LAN('E WI7'II ALI.WORKNIAN'S <br /> COMPENSATION LAWS. <br /> n�i llf a 1 ult ADVAiV( I,NOTICE, It1'QIAimi) P'()It INSPP'(,'Tl0NS <br /> )HED DATE h <br /> IN <br /> t. .l0 1�6 111-f ti 1,J11f?RI <br /> — 7. Il1T 14ti <br /> — - -- —— --— — -- lEI IIIA <br /> DEPARTMENT USE ONLY ffll <br /> Application Accepted By j\. Dale - Arca 11'2- EMI'1D# 4015- <br /> 4s <br /> 1 <br /> fz;- <br /> (Trout Inspection RY Datc Pump Insper. <br /> Destruction Inspection By Date <br /> COMMENTS: <br /> PE SC AMOUNT C ECKN RECEIVED DATE PERMIT/SERVICE REQUEST N INVOICE N WELL IDN <br /> CODES INFO REMn'TEU <br /> BY <br /> — <br /> 4390 050 0 t�,39 <br />