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3� <br /> WELLTUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISIO le-- <br /> 304 E.WEBER AVE,TI'H D FLOOR STOCKTON CA 95202 (209)468-3420 fL <br /> �,( <br /> NON-REFPERMIT EXPIRES 1 YEAR FROM DATE ISSUED T <br /> JOB ADDRESS (9 to) I/4TjY IZ_ APN 6 �- DJC �y <br /> CrrY/LIP S� C { (� �J 5--x 4-z-- —PARCEL SE <br /> OWNER NAME 4-lr7Z- ' P©'7'raj S L_fcJ6 ADDRESS y /-/7O0 GJ• Aln)Y �Z <br /> CrrY/zIP—LIa/ 0/ PHONE 33 3 — /_Z (o <br /> CONTRACTOR ..a,:,09,,C ADDDRESS�/zS�Z e!/ <br /> CrrY/LB SrnGlLra,J _g 77ZVF PHONE 7 4D —t�_'/ 5 C-57 LICENSE# I,./ <br /> XP DATE ;t 0 <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP_ RANGE SECTION <br /> TYPE OF WELL: O NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# -_-__❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. -�77 DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑OUT-0F-SERVICE WELL GEOTECHNICAL#. 6_ ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> n <br /> ❑INDUSTRIAL ❑OPEN BOTTOM -MM&EXCAVATION DIA 1-S CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELLCASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME 8,V41 NT" <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE.AW"DEPTH <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED TILLS 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 ANDTHAT HAT I AM IN COMPLIANCE WITH ALI,WORKMAN'S <br /> COMPENSATION LAWS. <br /> =)URNCE NOTICE REQUIRED F R INSPECTIONS <br /> SIGNED TITLE DATE <br /> B <br /> I <br /> �lt Ll1 <br /> 1 <br /> 1 <br /> PU8 fC ALI 7M 7M <br /> AL EA H N <br /> sPAR'C�tIF:NT�&EONLY--- ��2(�EMPID# <br /> Application Accepted By ` Dale <br /> Grout Inspection By Date—Pump Inspected By_ Date <br /> Destruction Inspection By Date <br /> z,dw <br /> COMMENTS: t 3uu A°f ST+ipce AL --VfD_SeaZM 1�}&>p!'aNChCtP 1..vP i4M-eg-7D FDic42 <br /> �-�/ Or _ <br /> aoktN( R.oC,¢4'k:,V 'ra 5-vNAr-oK PiltPrPAY 5016-TsP wVW TV,--,f7.9e.o.,r>-..2 "e' ,•aAll <br /> PE SC AMOUNT (CHECK#/ • RECEIVED DATE PERM rr/S- ER # INVOICE# WELLIDJI <br /> CODES INFO REMITTED CASH BY <br />