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L WELIRUMP PEPIVUT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION p� <br /> 304 E.WEBER AVE,THRID FLOOR STOCKCON CA 95202 (209)466-3420 9■v_ <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED p <br /> LJOB ADDRESS 211SG MAo::y4n k n Nn SAL r APN >_Ci `r�-�/ <br /> CTTYlZIP 1 rh,i\i C-iS -7 I,+ PARCELSIZE 24, Y7 <br /> OWNER NAME DDRESS <br /> GTTYrldP PHONE LA C:=?I <br /> CONTRACTOR FFP i 4n l f-i e( t rt L ADDRESS X A 1S�S <br /> CITY2B' TrG C\/ �I Ski 7 y� PHONE 2 S`..- Z \U C-57 LICENSE# EXP DATE_ <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP_ RANGE_SECTION <br /> TYPEOFWELU ❑ NEWWELL ❑ REPLACEMENTWELL ❑ MONITORING WELL 11 OTHER <br /> INSTALLATION S- ELLSYSTEMREPARR ❑CROSS.CONNECTREPAM ❑VAPOR EXTRACTION WELL# <br /> TYPEOFFUMP: ANEW ❑REPAIR H.P. Z DEPTH PUMP SET 5Ci FT. MST WATER LEVEL 'I <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED I1&E TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> O INDUSTRIAL 13 OPEN BOTTOM WELLEXCAVATIONDIA CONDUCTORCASINGDIA <br /> t `JZDOMESIICPRNATE 0 GRAVEL PACK/SIZE— WELLCASINGTYPE WELLCASWGDIA <br /> rLY ❑PUBLK/MUNICWAL 13 DRIVEN GROUTSEALDEPTH SPECIFICATION <br /> ❑MRIGATION/AG OTHER GROUT BRAND NAME <br /> LL ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRJ LER: ❑YES ❑NO <br /> APPROXIMATE WELLDEFIH <br /> PROPOSED CONSTRUCTION/DRILLING METHOD. MUD ROTARY_AIR ROTARY_AUGER CABLE_ OTHER 4 <br /> I HEREBY CERT0'Y THAT I HAVE PREPARED TINS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTT ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY C-57 LICENSE M CURRENT <br /> AND ACTIVE WITH TBE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> MIN IM{IM 2 IOUR AUNANCE NOTICE P.EQUIREU FOR INSPECTIONS ? <br /> {r SIGNED ( r TITLE Y7u PY1nTe°v b� DA �°'Z S <br /> F <br /> L 1 <br /> L <br /> n4 ,' <br /> DEPARTMENT USE ONLY <br /> APPIicad.AccePtW OY�'�"„-'�' - Diff -.� J'i ,? /L EMPIDN ? <br /> Grout 4upreuw BY Di1c Pump lrupenW BYp4k <br /> Dur 06M la,IxcI m BY Dmc <br /> COMMENTS: <br /> PE SC AMOUNT ECKW RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL 131# <br /> CODES INFO REMITTED BY <br /> 43gC OSO <br /> V <br />