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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 /> 2 22 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED/1, <br /> JOB ADDRESS 9307 E LN/E 0/i IG RD APN 003 —/Vf-ZD <br /> C 1,��2 PARCEL SIZE fi �0 4C� <br /> OWNER NAME 000 Y`' t-100TI ADDRESS ��;/% E LI VE OA-K. IL70A►,) <br /> IT <br /> CY/LIP1J-I '111 CA 4145-7.4 Z PHONE <br /> CONTRACTOR V4_� 12CILt,10(l ADDRESS PFb '5O)C JI <br /> CITY/L'P Ey r;�l��rI PHONE r1 I Q ____q_ —�1n0 C-57 LICENSE# EXP DATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_19�4 1241?I'OWNSHIP_ RANGE_ SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER __ <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECI•REPAIR ❑VAPOR EXTRACTION WELL# pEYMy9 + <br /> —�tEer_I��I=Q -- <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER NLEVyEyL <br /> 13 OUT-OF-SERVICE WELL GEOTECHNICAL# Tum 1 111 <br /> Z ❑SOI BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELLCONSTRUCTION SPECIFICATION SAN JOA01 16'. <br /> PUBLIC Hf f" <br /> ENVIRON!:'",'.:r, <br /> ❑INDUSTRIAL 13 OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA_ <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/S6E_ WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUTSEALDEPTH SPECIFICATION <br /> T SCAATIION^ p <br /> 13 IRRIGATION/AG OTHER GROUT BRAND NAME_Dek=N f( <br /> ❑MONITORING , lJ GROUT SEAL PUMPED: ❑YES ❑NO E <br /> ❑CHRISTY BOX ❑STOV&PIPE +J CONCRETE PEDESTAL BY DRI.LER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPTH /O 1_ �� U <br /> PROPOSED CONSTRUCIION/DRI-IJ•1G METHOD: MUD ROTARY_AIR ROTARY_AUGER_CABLE_ OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 1 <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY C-57 LICENSE IS CURRENT <br /> AND ACTIVE CALIFO C CTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> MINI OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> / <br /> SIGNED TITLE jRPXE 1� k)bt Woo 1� 0 <br /> C <br /> <• Cg: <br /> a <br /> .ca <br /> (xP.aLL) <br /> s <br /> va ]urer r • <br /> suw <br /> �w.. PROPOSED 9rEso rr) mi <br /> a <br /> raL,a.o I rn 7 i <br /> ' p:eOETe wrptu�nor+ ]{ 1µy. <br /> pYEN MUtE YYYY11tF <br /> xo a Ps <br /> �t <br /> u.vna.a w <br /> r <br /> y <br /> u <br /> 0 <br /> D/Rr/SWM IIxL YLlxll>f <br /> ( :U%f OAK ROAD <br /> DEPARTR7 'N T USE'ONLL' <br /> �. . <br /> Application Accepted By Date IR Area `/Z EMPID#aC qq <br /> Groot Inspection BY Date Pump Inspected BY Date <br /> Destruction Inspection By Date <br /> COMMENTS 'CvLre_-0VI. -�b S( <br /> PE SC AMOUNT kHEQWj RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL ID# <br /> CODES INFO I REMITTED ASH I BY <br /> Co 01 4bid - 3i nSO,eC�r, z1�, � h O jvlwa <br />