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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 /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Z 1J z <br /> CII'YIZIP l`/. � �1� / PARCEL SIZE A •,2 Af��C1 <br /> OWNER NAME ADDRESS SI C(� 1n JLv ISI,S{{LL L 4Aj< <br /> CrIYlLIP fae ovo OkL. 95.31)() PHONE S"Sl-zy3-SSS <br /> CONTRACTOR C A-OJ P IJ K CLl-j,5Lh-S-ADDRESS I T)60 {'F"`0-O W4 y / _ <br /> CITYr _ ✓VGf-�(__ PHONE�91J`�-1 2- /l3.6 C-57 LICENSE#�f / EXPUA7'E— <br /> GEOGRAPHICAI,INFORMATION- COORDINATES X Y TOWNSHIP___ RANGE_SECTION <br /> TYPEOFWELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: DWELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL.# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SETFT. FIRST WATER LEVEL _ <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING__- �7ESTRUCTION: -_ <br /> INTENDED USE TYPE OF WELL S SIC T <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA / CONDUCTOR CASING DLA- <br /> 0 DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE 5V-- WELL CASING DIA to <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME C P.'2 ✓� S (� <br /> ❑MONITORING GROUT SEAL PUMPED: >S'ES ❑NO "] <br /> ❑CHRISTY BOX ❑STOVE PIPE II CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO `^ <br /> APPROXIMATE WELLDEPTH <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY__..AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THF.WORK WILL BE DONE IN ACCORDANCE Wrl'H 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 /> MUM 24 HOUR ADVANCE NOTICE REQUIRE FOR INSPECTIONS <br /> SIGNED 7 TTIT_E_ V DATE_ <br /> I <br /> it <br /> _ - w <br /> L3 o �< <br /> -t�♦ <br /> I � <br /> DEPARTMENT USE ONLY <br /> Applimtion Accepted By - - - �— _ Date Area MPID# <br /> Grout Inspection By to<.� i Gump Inspected By Date <br /> Destruction Inspection By Datc <br /> COMMENTS: <br /> PE SC AMOUNT CHE #/ RECEIVED DATE PERM Ir/SERV ICE REQUEST# INVOICE# WELL IDN <br /> CODES INFO REMITTED ASH BY <br />