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r� WELL/PUMP PERMIT <br /> JOAQUIN COUNTYPUBLICHEALTH SERVICES ENVIRONMEN',, EALTH DIVISION <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 952(12 (209)468.3420 4r ; ;;a Li <br /> NONREFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> !OB ADDRESS 16SO4� r APN !�7— Z -0 / <br /> CTTYfZIP T-" LISiLa PARCELSIZE � A-�/2 s e <br /> Akk OWNER NAME_ ADDRESSC_ �AIIA <br /> 1 CTTYIZIP PHONE?Qg <br /> CONTRACITOR1Vt=+a. o. A,4ou>y,^a ADDRESS%s7 B,n14K!o1J L24 . <br /> 1 CTTYJZIP 1_00 1 _ C�- �ISZS, —PHONE 2C!?l li&-1 3t?Q I C-57 LICENSE#U,%QQ-4,--EXP DATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X— Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> 1 <br /> INSTALLATION: ❑WELL SYSTEM REPAIR - ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> M. TYPE OF PUMP: O.NEW. ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST'WATER LEVEL <br /> ❑OUT•OF-SERVICE WELL ❑GEOTECHNICAL# SOIL BORING-10 ❑DESTRUCTION: <br /> InENDED USE TYPE OF WELL <br /> I' <br /> -i7 INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION FIA CONDUCTOR CASQVG D1A <br /> ❑DOMESTIC PRIVATE ❑GRAVELPAMSIZE WELL CASING TYPE WELL CASING DLA- <br /> 0 PUBLICIMUNICIP AL <br /> IA❑PUBLICIMUNICIPAL CDRIVEN GROUTSEALDEPTH SPECIFICATION- <br /> 0 IRRiGATION/AG <br /> PECiP3CATI0N❑IRRIGATIONlAG OTHER GROUTBRANDNAME <br /> ❑MONITORING GROUT SEALPUMPED: O YES ❑NO <br /> ❑CHRISTY BOX Q STOVE PIPE ` CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> { -F <br /> APPROXIMATE WELLDEPTH SOI C �.3raYaQ <br /> f4 ,PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY_AIR ROTARY AUGER.-A CABLE OTHER <br /> IS I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANmWTI'H SAN <br /> 7OAQUIN 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 BOA"AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. O <br /> M IN111'IUM 23 HOUR ADVANCE NOT[CL RI?QUIRlsD FOR 1NS1'I,CTIONS <br /> I A�' SIGNED 1TTTLB 4-A'4- /aZ [ DATE r �G <br /> L ll <br /> i <br /> eo <br /> I <br /> I i <br /> { 1 <br /> , <br /> I F r <br /> r <br /> II �_ <br /> `' PlJrST� <br /> L.I hl[M1LTHI$[A IC- <br /> - <br /> vp I <br /> DEPARTMENT USE ONLY+ 1�C <br /> Application Accepted lly '//-__ !�'i'� � Date✓ 2 Area -W'2— EM PID# ` o <br /> Grout Inspection By D.I. Pump Inspected J/WBy Date <br /> I Deslruclion Inspcc ion n Dnlc G <br /> j <br /> COMML•NTS: y S fL <br /> PE SC AMOUNT RECEIVED DATE <br /> CODES INFO REMITTED CASH BY <br /> PERMTTISERVICEREQUEST# AVVOICE# WELL 04 <br /> Lf 3 a ISO ?3� lola. �a 2 d E <br />