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WELL/PUMP PERMIT <br /> 1 JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMEN' IALTH DIVISION <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (ZU9)468-3420 V <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED c/ 7 <br /> JOBADDRESS_10304 L-,Nvr enwo APN 1'27 S'3 2-0 / Z <br /> CITY/Z �ri4c�. cI�3 S� c PARCEL SIZE---3 <br /> OWNER NAME F> Cc r atT ADDRESS <br /> CITY/ZPHONE Z oet- a-3y" 34e12 <br /> CONTRACTOR CI, O• Ayo0 O-ac aII'- _ADDRESS :4 N r Q<xo j L-i <br /> C1TY2IPL001 _ CA 0IC7_iC 4. PHONE 2D4-�k 'S4-:1 1 C-57 LICENSEML�h�EXP DATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y_TOWNSHIP_ RANGE_SECTION T�� <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELLM ❑OTHER <br /> i <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL M <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET PT. FIRSTWATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# SOIL BORING 10 C7.MI. ❑DESTRUC ION: <br /> INTENDED US TYPE OF WF.. 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 GROUTSEALDEFM SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELLDEP7H IpI 1O <br /> PROPOSED CONSTRUCTTONMRILLING METHOD: MUD ROTARY_AIR ROTARY_AUGER_A CABLE_OTHER <br /> i I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE-1VITH 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 CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. O <br /> �1 h INIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED a► TITLE E4/Ciw"C DATE r'2 4Z <br /> if <br /> 1 <br /> :i-W <br /> F <br /> MN &( UG ita <br /> —PIIBLII;HF LTHSER111GES <br /> mr <br /> IV SIUr <br /> YQ <br /> DEPARTMENT USE ON(LLYY <br /> �1 <br /> Application Accepted By / ''� V j;!5t.�"i Date/ �"5' 7/ Area .2� EMPID# 7 E/�� <br /> Grout Inspection By Oat Pump Inspected By _Date <br /> Destruction Inslxc iwt o'<aik, IA Date <br /> COMMENTS: <br /> PE SC AMOUNT RECEIVED DATE PERMIT-/SERV ICE REQUEST# INVOICE# WELL IDM <br /> CODES INFO REMITTED CASH BY <br /> 43:71 X50 Vo 41ol, Lb 674z) C 16 c <br />