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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HP.ALTH DIVISION <br /> 304 E.WEBER AVE,THIRD 11- DOR STOCKTON CA 95202 (209)468.3420 <br /> 1 NUN-REFUND LE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> 79/ � / �J � rid t <br /> JOB ADDRESS 32,6 _ i C'lc'��KPP /ti'! APN `'� <br /> CI YrLm —Io C_ l�/�� <br /> �`` ,� L l _ A CEL SIZE Fc K <br /> O"ERNAMR Ah k � L/i(_ DDRESS�kl"Vie <br /> C'I'1'Y/ZIP_Z14-'o f-6-s_ C_C�v1 PHONE <br /> CONTRACTOR_ ADDRESS <br /> CITY)ZM PJIONE C-57 LICENSE# _-. _EXP DATE <br /> GEOGRAPHICAL INFY.`RMATION. COORDINATES X Y TOWNS111P RANCE SECTION <br /> 'I'YPE OF WELL: ❑ NEW WFIl. ❑ REPLACEMENT WELL ❑ MONrrOR[.NG WEII, _ 0 OTHER <br /> INSTALLATION: O WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. ITRS T WATER LEVEL <br /> )(OUT-OF-SERVICE WELL ❑GEOTECHNICAL# _-. O SOIL BORING _ ❑DESTRUCTION: <br /> INTENDED-DECD CSE TYPf::OF mm, CONSTRUCTION SPECIFI ATION <br /> ❑INDUS'TRIAL ❑OPEN BOTTOM WFLI.EXCAVATION DSA CONDUCTOR CASING DIA <br /> O DOMESTIC PRIVATE O GRi:VEL PACK/SIZE WELL CASING TYPE WELLCASING DIA <br /> ❑PL)BLICJMUNICIPAL ❑DRIVEN GROUT SEAL DE!'TH L SPECIFICATION <br /> — <br /> 13 IRRIGATION/AG OTIIER GROUT BRAND NAME--__. —_-_ <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES O NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE. WE,LLDEP114, <br /> PROPOSED CONSTRUCTION/DRILLING METIIOD: MUD ROTARY AIR RO'T'ARY AUGER CABLE . _ OTHER <br /> I HEREBY CERTIFY 77IAT I IIAVE PREPARED TRIS APPLICATION AND THAT THE WORK WILL.BE DONE IN ACCORDANCE WL771 SAN ` <br /> JOAQUIN C.OU. INANCFS,. LAWS,AND RULES AND RECULATIONS. I ALSO CERTIFY TILT MY C-57 LICF:NSK LS CURRENT <br /> AND A ITH TH CALIFO IA CO TRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE 1AIT11 ALL WORKMAN'S <br /> COMPENS,tTION LAWS. r <br /> MI IA1UM 110 VANCE NOTICE REQUIRED FOR INSPECTIONS C <br /> SI NED 1 Tn.F - DATE <br /> C <br /> 01 <br /> lol <br /> — - <br /> - L - - <br /> ��. <br /> i <br /> - —_ -r <br /> - - <br /> DEPARTMENT USIEONLY G(0 Ll 114 <br /> Application Accepted By • Date. r Area 0_1 L -EMPID#__ <br /> Grout Inspection By _Date_ _,_Pump Inspecltxl By CAr^4,5 �/Com. �P , —Date- <br /> Destruction Insptx;tion By __ pate <br /> COMMENTS: HA -ea rP <br /> ['E SC AMOUNT HEO'K RECEIVED DATE TT7SEKVICERF.QLIEb # INVOICE# WELL WO <br /> CODES INR) REMTTL'F_D CASH BY <br />