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WELUPUMP 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 /> D '/ NON-RE ABLE PE E7C�IRES I YEAR FROM DATE ISSUED <br /> H/. r CJr S <br /> JOB ADDRESS APN <br /> CPI,Y/LIP PARCEL SIZE <br /> OWNER NAM DRESS O <br /> CITY/L� PHONE ///��7 <br /> CONTRACTOR J ADDDfR,E,SSS /��j' /�(-,+ •• D <br /> CITY2� PHONE,' '(L/ 6yy ' - C 5 %tp4 . EU DATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y_ TOWNSHIP_ RANGE- SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CRO S-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑.NEW D(REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOI.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_ WELLCASINGTYPE WELLCASINGDIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUTSEALDEP H SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES O NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTIONIDRI.LING METHOD: MUD ROTARY_AIR ROTARY-AUGER-CABLE_ OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORE 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 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE DATE <br />