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WELL/PUNIP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEAuTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 A <br /> 2 + <br /> NON-REFUNDABLE PER,NIITJEXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ' �1 7S bla d611-e 17 IV/ A- <br /> CITY/Z[P ����G1 �� PARCEL SIZE <br /> OWNER NAME gkh�P-/1' Cl `�J� ADDRESS rJ y;7f V174 611 ''!1 t? / r <br /> CITY/Zip Vc'C/f/t� PHONE �S�G <br /> CONTRACTOR ADDRESS <br /> CITY/ZIP 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# THER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECTREPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ 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 /> OMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN �' '. ;,y ' GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING i " 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 /> NIIN74 ) _ HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE v ry 1l lod DATE <br /> c <br /> PARCEL 1 g — <br /> 157.00 AcaIs Di R <br /> PROPOSED LOT UNE <br /> O <br /> PROPOSED LOT LINE 7'100 y Z <br /> _ PARCEL 2 J <br /> a <br /> 60.00 AcaE7 � <br /> > <br /> e LAT UMC TO <br /> T &ADAMOONE0 <br /> —}-'—*- I PROPERII NE IS <br /> Of 7LOU4 1 <br /> APPROX.CAECR <br />