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WELL/PUMP PERMIT <br /> SAN JOAQUt1V COUNTY PUBLIC HEALTH SER VICES ENVIRONMENtI HEALTH DIVISION <br /> E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 <br /> t NON-REFUNDABLE PERMIT EXPIRI ,FJYOM ATE I SUED <br /> JOB ADDRESS S� rFAO" fm*, <br /> ,[f� �r1,t j�'f`=: <br /> CITY/ZIP a ��u •t:� N- a +_ Zo I <br /> 1Sz/z 4 --0 <br /> OWNER NAM PARCEL PARCEL SIZE �Gl <br /> t ADDRESS lOa a$~ .00 <br /> t�dt�ro <br /> CONTRACTOR CJ � PHONE <br /> f ADDRESS ', <br /> CITY/Zlp CJ !J •� �z ! j r �� , <br /> PHONE C-57 LICENSE#—gam ,� <br /> EXP DATE ,�� <br /> GEOGRAPHICAL INFORMATION: COORDINATES X <br /> Y TOWNSHIP RANGE SECTIO70THER TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ <br /> MONITORING WELL# ❑ <br /> INSTALLATION: ❑WELL SYSTEM REPAIR O CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑,NEW Ar REPAIR H.P. <br /> -- �— DEPTH PUMP SET R FT. FIRST WATE❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTI <br /> INTENDED USE YP F WELL_ <br /> co <br /> T U I NS C p <br /> Q INDUSTRIAL ❑OPEN BOTTOM <br /> DK_EXCAVATION D � CONDUCTOR CASING DIA i <br /> d2') MESTIC PRIVATE ❑GRAVEL PACK/SIZE <br /> WELL CASING TYPE WELL CASING DIA 7 <br /> ❑PUBLIClMUNICIPAL ❑DRIVEN I <br /> GROUT SEAL DEPTH SPECIFICATION <br /> 13IRRIGATION/AG <br /> CJ MONITORING OTHER GROUT BRAND NAME <br /> GROUT SEAL PUMPED: M YES ❑NO <br /> ❑CHRIST Y BOX [3 STOVE PIPE /yCONCRETE PEDESTAL BY DRILLER: ❑YES 13NO <br /> r <br /> APPROXIMATE WELL DEPTH �1�' <br /> PROPOSED CONSTRUCTION/DRILLING 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 <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. I <br /> MINIMUM 24 HOUR ADVANCE;NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED <br /> DATE �/J�lei <br /> I <br /> '4-4-F <br /> r w:4= <br /> i <br /> h r,c <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date `tlA— EMPID# T <br /> Grout Inspection By Date Pump InspectedB Date <br /> Destruction Inspection By Date <br /> COMMENTS: <br /> I <br /> PE Sc AMOUNT CHEC RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL ID# <br /> CODES INFO REMITTED ASH BY. <br />