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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 P <br /> NON-REFUNDABLE PERMXT EXPIRES 1 YEAR FROM DATE ISSUED I1 <br /> JOB ADDRESS C .Lq � I"V APN <br /> CITy/ZIP ��lD'�' �L PARCEL SIZE '.4 a- CYC <br /> OWNER NAME w 1 �tl.Y� • 1V t\�U O�ADDRESS <br /> C /Z "(\ PHONE G 9 - s 4 "7 a y/ <br /> CONTRACTOR ADDRE <br /> CITy/ZIp PHONE C-57 LICENSE# EXP DATE <br /> r: <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP NGE SECT`IO,N� <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# .OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# ///��l��\ <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT.. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL 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 GROUT SEAL DEPTH 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 WELL DEP7•H <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> - <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL 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 I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> N 'MUM <br /> 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED L�,f\_� � TI'i1.E� DATE- <br /> . �4 \ <br /> ` I (� <br /> 5- <br /> �, EE <br /> "� SIJ; �. „e•,� ,�+ t ' I <br /> Ftl 'i n <br /> �j �� DEfP��R(�TMENT USE ONLY 2 <br /> Application Accepted By co 'i � tl� Date__��� � Area � M[�[[7M 9 27 <br /> Grout Inspection By Date Pump Inspected By Dat <br /> Destruction Inspectio By Date <br /> COMMENTS: G2 <br /> PE Sc AMOUNT RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE Of WELL ID# <br /> CODES INFO REM D CASH BY <br /> ly7 8D� X00 g�S 2 <br />