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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 /> , _ Y UA1NON-RE�FU'NPDABL PERMIT EXPIRES <br /> XPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ow 4j t 06jA� APN �I�()9 <br /> ~ UlfG l� <br /> C(0 ` <br /> `3 � <br /> CITY/ZIP 5 3 PARCEEL SIZE <br /> OWNER NAMrS CV �d W(+LDRESS J IVU C"\V-1'. S re�� <br /> CITYIZIP eVA PIIONFj) ra.A_ <br /> CONTRACTOR t �� C y, 1_A6yI ADDRESS 6_022- ke1AQC ,q(? Ctk/ <br /> CTY/ZIPF-1 gSjIL2 Z PHONE_q.j <br /> q! <br /> �--10 C-57 LICENSE#3tp(6342EXPD7'E <br /> 9 30 <br /> ZUU <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSIIIP2 S RANGE APSECTION (1__ <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# / <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# I�]SOIL BORING�25 _�S • ❑DESTRUCL'ION: <br /> INTENDED USEt TYPE OF WELL !` CONSTRUCTION SPFC1FICATION <br /> N❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING D,f,AI <br /> ❑ DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE- WELL CASING DIA <br /> ❑PUBLICIMUNICIPAL 17 DRIVEN GROUTSEALDEPTH PIT SPECIFICATION � <br /> ❑ IRRIGATION/AG OTHER GROUT BRAND NAME ce'/ ie'm <br /> � fNCr C PO��GI1r1,Cf�Q I h�CS�yfn+f0k\. GROUT SEAL PUMPED: �ES ❑NO <br /> CCJJ C7 <br /> ❑CHRISTY BOX ❑STOVE PIPE y., CONCRETE PEDESTAL BY DRILLER: ❑YES ANO Ir, <br /> APPROXIMATEL DEPTH <br /> I�q <br /> PROPOSED CONSTACTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> Z <br /> I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE 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 Z <br /> AND ACTIVE, 1TH THE 6-LIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S c'.'s <br /> COMPENSATION LAWS. s <br /> MIN MUM 24 HOU ADVANCE,NOTICE REQUIRED FOR INSPECTIONS <br /> c 1 1 <br /> SIGNED TTTLE 9� � l `� DATEJV <br /> V1Z I <br /> C <br /> jo <br /> V <br /> HE ;•tv., <br /> (�] DEPARTMENT USE ONLY —7 7 p <br /> Application Accepted By L U Date LG r Area EMPID# J }a <br /> Grout Inspection By ate Pump Inspected By Date <br /> Destruction Inspection By Date <br /> COMMENTS: <br /> PE SC AMOUNT CHEC RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL ID# <br /> CODES INFO REMITTED CASH BY <br /> ' 312 <br /> 623 0 /Kl! -Z . ( Uk 301 ` -I <br />