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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION }L 7 <br /> 304 E.WEBER AVE.THIRD FLOOR STOCKTON CA 95202 (209)468-3420 "� l/ <br /> 9`r'UN�A6�L E'P I S EAR FROM DAT'I UED f <br /> 108 ADDRESS�OZZG]—� SI jays GGyq . s 0�� <br /> APN <br /> CTTY/Zlp <M=N moi) � PARCEL SIZE 6? d% . <br /> OWNER NAME ADDRESS <br /> o q( <br /> CTI�'/Z1P L_ PHONE <br /> CONTRACTOR k i ��4r4DP_a . D 't AO'AADDRESS -7V V 4"P4 1 <br /> CITY/Z <br /> IP_CZ2a PHONE C-57 LICENSE#��tEXP DATE 3 <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP_ RANGE— SECTION <br /> TYPE OF WELL: NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL It ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTHH PUMP SET FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# yp SOIL BORIN ❑DESTRUCTION: <br /> C_ v Z' a 3a i� <br /> INTENDED USE TYPE OF WELL, CONSTRUCTION SPECIFICATION <br /> !! I <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA/ ,, CONDUCTOR CASING DIA <br /> MESTIC PRIVATE ❑GRAVEL PACK/SIZE_ WELL CASING TYPE _ ll WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROAT SEAL DEPI•H Ir <br /> t,,e ff SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME g;06f Cu7.4((y <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ,e ,;o <br /> ❑CHRISTY BOX ❑STOVE PIPE / CONCRETE PEDESTAL BY DRILLER: ❑YES J'd'rqro' <br /> APPROXIMATE WELL DEPTH ¢� l. ld'TO ! S� <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY - AUGER CABLE OTHER <br /> 1 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 /> MINIMUM 24 1-1OUR ADVANCE NOTICEREQUIRED FOR INSPIiCTIONS <br /> SIGNED TITLEL 'Y/I �ir[GLY�Z DATE yO� <br /> _ .........- __ _. .-.J be i... <br /> 0 <br /> �- <br /> o <br /> B <br /> i � NCO <br /> —.—.--_.— '✓ICES <br /> �IVI!gr:. <br /> .G• _.-..._._.__. ... <br /> UIGLON�k NU�RPft <br /> n ,//I- - EPAR'I'MENT USE ONLY <br /> Application Accepted By �W�_- Date !Area EMPID#� <br /> Grout Inspection By /V Date Pump Inspected By Date <br /> Destruction Inspection By Dale Q?� <br /> COMMENTS: <br /> PE SC AMOUNT rHECK0 RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL ID# <br /> CODES IN EMITTED -CASH BY <br /> Z 15- f 230 16),q9s VI/O S(LQo S Z <br />