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WELL/PUMP PERMIT ' <br /> SAN IOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 <br /> rr <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> Lf " <br /> ]OB ADDRESS - / �• It © 6g— APN <br /> I xSRC <br /> CITY1ZIP ,�y,�c PARCEL SIZE <br /> OWNER NAME,,,.,, V �O/�sL Y�ADDRESS <br /> PHONE_ 3✓S <br /> CITY2� -- <br /> CONTRACTOR W& i, � jD[ t FPB- IIDRES <br /> CITY/ZIP � G,f __PHONE �� / C-57 LICENSE# EXP DATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: ❑ NEW WELL L7 REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW x REPAIR H.P._ ..[� DEPTH PUMP SET (U FT. FIRST WATER LEVEL J <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> " I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL.CASING TYPE WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX 0 STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO I, <br /> APPROXIMATE WELL DEPTH 100 a <br /> PROPOSED CONSTRUCTION/DRELLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 'S <br /> I HEREBY 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 <br /> AND ACTIVE WITH THE CALIFORNIA CON'T'RACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> M 24 HOkIR ADVANCE NOTICE REQfUIR D FOR INSPECTIONS <br /> SIGNED � TITLE—--74DATE A/'o2 <br /> r <br /> ! <br /> 1 <br /> ! 1 <br /> r ' <br /> i <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date �OArea MPID# <br /> S" <br /> Grout Inspection By. Date Pump Inspected By Date 2. <br /> Destruction.Inspection By Date <br /> COMMENTS: <br /> PE Sc AMOUNT —'RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL ID# <br /> ' CODES INFO REMI'I"rED CASH BY <br /> 113 az- � �� D 0S <br />