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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMBNTAL HEALTH DIVISION h-Y <br /> 304 E.WEBER AVE.THIRD FLOOR STOCKTION CA 95202 (204)468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE 155UED <br /> JOB ADDRESS <br /> «�SS233 S klv ?6k „ 5��0f D - 41 <br /> �7 -- ARCEEL S d 3 <br /> OWNER NAME ��' ` Z ADDRESS " 3 2-3� �`y s7✓C <br /> i:fFYrLJP r`'r'�'� f APHONE r3L- 2 fl a <br /> CONTRACTOR— DIURESS / f <br /> � Cfl'Y/21P PHONE�D9— CcG 7_�„q��—C-57 LICE:A]SEq� -XP DATE��7 <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y—TOWNSHIP_ RANGE SECTION <br /> '41W OF WELL- 44:—NBW WELL CI REPLACEMENT WELL O MONITORINO WELL# 0 THIm <br /> INSTALLATION: d WELL SYSTEM REPAIR O CROSS-CONNECT REPAIR Cl VAPOR EXTRACTION WELLM <br /> TYPE OF PUMP: 04NEW CI REPAIR H.P. DEPTH PUMP SET 1. FIRST WATER LEVEL <br /> 0OUT-OP-SERVICE WELL ❑OBOTECHNICALff D SOIL BORING d DESTRUCTION: <br /> INTENDED USF. TYPE OF y <br /> j a <br /> j 0 INDUSTRIAL - ❑OPEN BOMM WELL EXCAVATION DIA�� CONDUCTOR CASING fjJA= <br /> Ik DOMESTIC PRIVATE fN ;RAVEL PACK/SIZF WELL CASING TYPE�fC"— WELLCASING DIA <br /> C3 PUBLICIMUNICIPAL R DRYVE1I GROUT SEAL DEPTH (a= SPECMTCATION <br /> 11 IRRIGATION)AG OTHER GROUT BRAND NAME <br /> CI MON MIMING GROUT SEAL PUMPED: f 7(ES d NO <br /> I C]CHR1sfY BOX [ STOVE PIPE CONCRPM PEDESTAL BY DRILLER: DYES O NO <br /> APPROXIMATE WELL. <br /> PROPOSED CONSTRUCIONlDRWNGMETHOD; MUD ROTARYD<__AIR ROTARY AUGER CABLE OMER_ <br /> I HEREBY CERTIFY THAT I HAVE PREPA RED THIS APPLICATION ANA THAT THE WORK WILL BE]DONE IN ACCORDANCE WITH SAN <br /> 1'OAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS.I ALSO CERTIFY THAT MY C-57 LICENSE fS CURRENT <br /> AND ACTIVE WITH TIIE CALIFORNIA CONTRACTORS STATE LICE.NS$BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> Nil UM 24 HOUI{ADVANCE NOTICE RFQ ED it R INSPECTIONS <br /> S'.IGNflD �— <br /> TM_E <br /> I <br /> FM <br /> 10 <br /> I - <br /> I •u I` <br /> DEPARTMENT USE ONLY <br /> I <br /> Applieation Acceplud Ey' D Z <br /> n Ate. PE]a <br /> Omot Iwp�k-By ` - Date JO"C� Inspeetad By <br /> ___Da <br /> Ikstructloa Inaxctian By Oe1c <br /> COMMENTS: &rw <br /> PZ' SC AMOUNT RECEIVED r DATE 10EREQUESTSINYO[C81t <br /> CODES IN Fn REMITTED CASH BY WEiJ-�M <br /> y�zdro gb Zz5 �a � z_ oD• <br /> aof 75, X30 3 <br /> i <br />