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WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 / ? NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS 45- -7O �IA e — Y— APN AAPN 61 CITY/ZIPr 1 'i��J..�^ / PARCEL SIZE OWNER NAME x(qRl� Zf L'S J ADS �r CITY/ZIP PHONE CONTRACTOR C� �y�� ff n ADDRESS CITY/ZB' i�r/�CZF-„lam AT PHONE 72?-S 5_4- C-57 LICENSE EXP DATE! GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION TYPE OF WELL: IH' NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRA(T10N WELL# TYPE OF PUMP: fB-NEW 11 REPAIR H.P.__ _ DEPTH PUMP SET FT. FIRST WATER LEVEL ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION 1 ❑INDUSTRIAL a{ PEN BOTTOM WELL EXCAVATION DIA 12--"1 CONDUCTOR CASING DIA []'DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE S7�• WELL CASING DIA ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH /!P, SPECIFICATION ❑IRRIGATION/AG OTHER GROUT BRAND NAME ❑MONITORING GROUT SEAL PUMPED: ❑YES a<o _. ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: 9-Y�S ❑NO APPROXIMATE WELL DEPTH 3&o PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY C-57 LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S COMPENSATION LAWS. MINIMU 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE ,!/`Y DATE oe- S 4 r L S - M T � -r n