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*ft, WELL/PUMP PERMIT r,.,. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 gU r <br /> D <br /> _NO FUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED / <br /> JOB ADDR SS �f� "�7 { (��'d- L �l APN �3 U _/ <br /> CITY/Z �—' <br /> � /PARCEL SIZE <br /> Q,� <br /> OWNER NAME ADDRESSC�L�I� <br /> CTTY/ZIP PHONE <br /> CONTRAACCT�O-/may teCJ �✓�G ADDRESS L r <br /> C X19 . i �rO'):7"r, C74 / —PHONE—M l L–/ C-57 LICENSE# XP 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 ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: 1� 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 DEPTH <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. <br /> 11 UM 24 qOUR ADVANCE NOTICE RE UIRED FOR INSPECTIONS <br /> SIGNED TITL <br /> DATE C <br /> r - <br /> PI It I irl, <br /> IV <br /> EN IRr 'N41 <br /> I <br /> 1 <br /> DEPARTMENT USE ONLY <br /> 9 Application Accepted By Date � Area EMPID# <br /> Grout Inspection By DatePump Inspected B `A 4 Date- <br /> i <br /> Destruction Inspection By Date <br /> COMMENTS: <br /> PE SC AMOUNT CHECK# RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL ID# <br /> CODES INFO REMITTED H BY <br /> 1 oqq o �' v i 7L2 2 q775- <br />