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I WELI;/PUMP PERMIT <br /> SAN JOAQUIN -OUNTY PUBLIC HEALTH SERVICES ENVIRONMENTEALTH DIVISION y <br /> 304 E.WEBER AVE,,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 <br /> /NON-REFUNDIAB,L�1E PERMIT EXPIRES 1 YEAR FROM DATE ISSUED " <br /> JOB ADDRESS_ 5 �.�i V 1�IG// I .. ! ^� ---� APN <br />'i CITY/ZIPI /Q�/�d /. - " PARCELS <br /> k <br /> OWNER NAME )5 -ell C4.5r.7ft,Ci ADDRESS /7 ..�/a✓J' //f� �� _ <br /> 7-I `� -- — / CSU <br /> jf CITY/ZIPC/►/a� PHONE V67 <br /> CONTRACTOR ADDRESS v µ <br /> CITY/ZIP. .''. PHONE" <br /> C-57 LICENSE# EXP DATE <br /> GEOGRAPHICAL.INFORMATION: COORDINATES X__- Y TOWNSHIP RANGE SECTION . . <br /> TYPE OF WELL: 0 NEW WELL ❑ REPLACEMENT WELL :'O MONITORING WELL# THER <br /> INSTALLATION: 0 WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: Q NEW ❑REPAIR H.P: DEPTH Pump SET FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL it .❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION"DIA CONDUCTOR CASING DIA <br /> { <br /> 6MESTIC PRIVATE ❑GRAVEL PACK/SIZE" WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN PAYM E N ` " GROUT SEAT,DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG" OTHER GROUT-BRAND NAME <br /> ❑MONITORING. -r L GROUT SEAL PUMPED: ❑YES 13 NO" <br /> ❑CHRISTY BOX ...: ❑STOVE PIPE SAN JGttC]UN� yUNI CONCRETE PEDESTAL BY DRILLER:'.❑YES ❑NO' " <br /> PUBLIC HFA!TH SF,-1r!CES <br /> FNAR0N%tNTk <br /> APPROXIMATE WELL DEPTH h <br /> I <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 /> MIN HOPR ApVANCE!NOTICE REQUIR1�E,D FOR INSPECTIONS <br /> SIGNED k TITLE �t'V DATE. <br /> rlfy <br /> PARCEL 1 <br /> 167.00 ACRES <br /> PROPOSED LOT LINE ` <br /> Yc 6 <br /> C7 <br /> PROPOSED LOT LM .3700't � <br /> LJ C <br /> PARCEL 2 <br /> J ti f� 1�• MOO ACRES <br /> 'LOT LINE 70 _ <br /> 4 BE ABANOONEO <br /> I PROPERTY i TAE IS[ - <br /> ��CC !X 5LO0p1 � <br /> .APPRO7.CREEK - <br /> BANK <br /> DEPARTMENT USE ONLY r Q <br /> Application Accepted By4V' r. Date !{ Area ! EMPID# � <br /> Groat Inspection By Da - Pump Inspected By Date <br /> Destruction Inspection ay 4 Date <br /> COMMENTS: Bu "µ <br /> PE SC AMOUNT- C RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL ID# <br /> •BES INFO REMITTED CASH BY 1g <br />