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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)468-3470 <br /> NON. ABLE PER IRES I YEAR FROM DATE ISSUED <br /> t <br /> JOB ADDRESS O APN <br /> -7 Ll S':" <br /> (fj -,z 2—j V4 <br /> CrNarp ARCEL SIZE <br /> OWNER NAM DRESS <br /> CITY26' C, ONE <br /> CONTRACTOR ✓ DDRFSS <br /> CITYlZIP HONE ] ►`�'I C-57 LICENSER EXP DATE <br /> GEOGRAPHJCALINFORMATION: COORDINATES X-_ X TOWNSHIP RANGE_SECTION <br /> TYPEOF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL ti ❑OTHER <br /> INSTALLATION: {]WELL SYSTEM REPAIR p CROPS-CONNEC1'REPAIR 0 VAPOR EXTRACTION WELL <br /> 1 <br /> TYPEOFPUMP: ❑ NEW JREPAIR H.P. DEPTH PUMPSLrr .Ff. FIRST WATER LEVEL <br /> f U OUT-0F-SERVICE.WELL ❑GEOTECHNICAL# ❑SOLE.BORING p DESTRUCTION: <br /> 1 1lII'ENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION. �I <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DLA— <br /> C]DOMESTIC PRIVATE <br /> IA❑DOMESTICPRIVATE ❑GRAVEL PACIUSMR WELL CASINO TYPE_-_ WELL CASING DIA <br /> ❑PUBLICIMUNICIPAL ❑DRIVEN GROIII'SEALDEi-M SPECIFICATION <br /> ❑02RIGAT[ON1AG OTHER GROUT BRAND NAME -11? <br /> ❑MONITORING GROUT SEAL PUMPED: O YES ❑NO l <br /> fl <br /> M CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRIEJ.ER: ❑YES ❑NO <br /> S <br /> APPROXIMATE WELL DEPTH - <br /> PROPOSED CONSTRUCTION(DRLI.LING METHOD: MUD ROTARY_AIR ROTARY AUGER CABLE OTHER_ <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WELL 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 CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> � y <br /> SIGNED TITLE DATE <br /> i <br /> J <br /> i <br /> llez C . . <br /> NI -41 r <br /> DF <br /> RTIVUZiT USE ONLY q!� <br /> Application Accepted By le <br /> Grout Inspection By to Pump Inspected By to D <br /> Destruction Inspection By pau <br /> t <br /> COMMENTS: <br /> PE SC AMOUNT ECK*1 RECEIVED DATE PERMR'/SERVICE REQUEST9 INVOICE it WELLMN <br /> CODES PEPO REMI[TED BY <br /> --1 ZZ5 <br />