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WELUPUMP PERMIT <br /> SAN JOAQUINCOUN'IY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PUMP 304 E.WEBER AVE.THIRD FLOOR STOCKTON CA 95202 (209)468-3420 ■lnYrj�, <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED {■rJ <br /> JOB ADDRESS 2i 1G'f -%k.iLAAPN <br /> CITYIZIP rf&lc V PARCEL SIZE 2�4 <br /> �I�LT(d7—,4 /.z^ <br /> OWNBR NAME I E rle v o4 1'r—l'" ADDRESS <br /> CITY 2IP_ PHONE <br /> CONTRACTOR Fre I: ri 5 E-i Fr irk C_ ADDRESS "C' \SG1 <br /> 6 CJTY/ZB' 1 rG C�! �I S3 7� PHONE Y 3 S— Z�1 t4 C-5'/LICENSE# EXP DATE <br /> LGEOGRAPHICAL INFORMATION: COORDINATES X_ Y TOWNSHIP_ RANGE_SECTION <br /> I_ TYPEOFWKLL: 13NEWWELL 10REPLACEMENTWELL ❑ MONITORING WELL# ❑OTHER <br /> 4 IWIR ❑ <br /> NSTALLATION & ELL SYSTEM REPAIR REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPEOFPUMP: JZ-NEW ❑REPAIR H.P. Z DEPTH PUMP SET 6G FT. FIRST WATER LEVEL il<; <br /> ❑OUT-OFSER V ICE WELL ❑GBOTECHNICAL# ❑SOR.BORING ❑DESTRUCTION: <br /> ][NTEWED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELLEXCAVATION DU CONDUCTOR CASING DIA_ <br /> 9fDOMPSTIC PRIVATE ❑GRAVEL PACK/SIZE_ WELLCASINGTYPE WELLCASINGDIA <br /> ❑PUBLICIMUNICIAL ❑DRIVEN GROUTSEALDEFTH SPECI'ICATION <br /> ❑MRIGATION/AG OTHER GROUT BRAND NAME <br /> ` 13MONITORING GROUT SEAL PUMPED: ❑YES ❑NO F <br /> L ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTION/DRRIAJG METHOD: MUD ROTARY_ABR ROTARY_AUGER_CABLE OTHER <br /> I HEREBY CERTIFY THAT I RAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN n <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS I ALSO CERTIFY THAT MY C-51 LICENSE IS CURRENT y <br /> AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> { COMPENSATION LAWS y <br /> LMINIMUM Z OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED— TITLE Y\iimp-me^rF, DATE <br /> CF <br /> C <br /> el,-3j: <br /> u L <br /> i <br /> � /,f/./�j DEPARTMENT USE ONLY <br /> LAppli®rim Accep¢ Bye'j/I /F Da¢ `��y —EMPIDW h' <br /> AGtIuspretim By Dale A mn 6ispenW Bye '� <br /> roulr1.Ylii.. Da -• <br /> De cdm Inspeuim By n.le <br /> i. COMMENTS- <br /> PET SC AMOUNTCK#1 IT/ <br /> RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL M# <br /> � CODES INFO REMITTED BY <br /> 438C) O5-0 60co l y3 o 2 <br />