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WELL/PUMP 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 /> F5NO—REFFFNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS (S 1 l v`^� L APN 09 1 -o-/5Q a �_P5 <br /> CTTY/lIP L//n P Yl 1 0� 9 z 31.Q T7 ems,,,' /- PARCEL SIZE 1 8 <br /> OWNER NAME JN n n Q M rbVPJ ADDRESS r C UVX 10 ,1 LI nden 0 19__ q S 2 <br /> CTTYlLIP r PHONE <br /> CONTRACTOR n ADDRESS <br /> CITY/LIP t PHONE C-57 LICENSE# EXP 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: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑OUT-OP-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING __ XDESTRUCTION: LESs-w*v C9 <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 DLA- <br /> 0 KJBLIC/MUNICIPAL <br /> IA❑PUBLiC/MUNICIPAL ❑DRIVEN GROUTSEALDEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONTTORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPS 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 1 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 /> MI MUM 24 HOUR ADVANCF",NOTICE REQUIRED FOR INSPECTIONS <br /> TITLE E=s-. O/SIGNED i � <br /> V' <br /> HEC f=1 A <br /> 4-1 <br /> JO O <br /> AL H <br /> FAITH <br /> -- _ DEPARTMENT USE ONLY <br /> Application Accepted By.. Date Area <br /> Grout Inspection By to Pump Inspected Byq Date <br /> Destruction Inspection B Date `— CC r-]_C <br /> COMMENTS: '�y�dee GLE4`7b $f n5 Z b <br /> PE SC AMOUNT CHEC RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL LIN# <br /> CODES INFO REMITTED BY <br /> �3 73 l&/ uv- io.39s C6 -I9/P as 9 8 <br /> 5�2 ©2 <br />