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WELL/PUMP PERMIT WELL SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468.3420 <br /> Al <br /> NON REFUNDABLE PEMYFAR FROM DATE ISSUED /7 <br /> JOB ADDRESS APf�_g�!/�lT <br /> s <br /> Crryf. P .------PARCEL ST/,, <br /> OWNER NAME L DR f , 7 / <br /> CITY/ZiP <br /> f 5 Z v <br /> CONTRACTO T S C I K DRESS I <br /> CITY� a�ll 5 PHONE-2 !9�(J C-57 LICENSE49W, DATfiT <br /> GEOGRAPHICAL <br /> � ,_INFORMATION: COORDINATES XY TOWNSHIP RANGE,SECTION <br /> ✓ <br /> TYPE OF WELL:I`� NEW WELL ❑ RBPLACEMENT WELL ❑ MONITORING WELL M ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL M <br /> TYPE OF RUMP. O NEW O REPAIR H.P. DEPTH PUMP SET K. FIRST WATER LEVEL <br /> ❑OU T-0FSIR VICE WELL ❑GEOTECHNICAL i! ❑SOI.BORING ❑DESTRUCTION: <br /> ENDED USE T PE OF=I. CONSTRUCTION SPECIE'CA ON <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL,EXCAVATION DIA_jiZ/CONDUCTOR CASING DIA`_ <br /> DOMESTIC PRIVATE >�_RAVEL PACK/SIZR WELL CASING TYP`,l i WELLCASING DIA io_ <br /> ❑PUBUfP <br /> CIMUNICAL ❑DRIVEN PAYMENT FIECEIVf=D GROUTSEALDEPTH_/00����//r_ SPEK�CII'IC-ASTON <br /> 13 <br /> IRRIGATION/A0 OTHER GROUT BRAND NAME W A y �.. <br /> ❑MONITORING SEP 1 O ZOO <br /> GROUT SP.A[.PUMPED: ❑NO <br /> SAN JOA:;I:rl <br /> C3 CHRISTY BOX O STOVE PSE NU <br /> CJUY CONCRSTE PEDESTAL BY DRILLER: ❑YESO <br /> PU1�:C I It AL[h 4QvidS L <br /> fW l ll:`.�I:!I m",I:i Al 1:1 FA,13)ON <br /> APPROXIMATE WELLDEPTH_z=9212 <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTWY TRAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> 3OAQUIN COUNTY ORDI[NANCFS,STATE LAWS,AND RULES AND REGULAT]IONS. I ALSO CERTIFY THAT MY C-57 LICENSE IB CURRENT <br /> AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITEI ALL WORXMAN'S <br /> COMPENSATION LAWS. <br /> / � ( 'MINIMUM 24 OUR ADVANCE NOTICE REQUIREDFORINSPECTIONS <br /> SIGNED --TITLE 1rAl r6 Qy1 DA <br /> DEPA US Y <br /> Application Accepted By U A�_ P -`�Lp <br /> El <br /> Grout Inspection BY to mp Inspected By _Date <br /> Destruction Inspection By Date <br /> COMMENTS: <br /> PE SC AMOUNTHEC RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WEI. 09 <br /> CODES /NPO REMITTED H BY <br /> 9p 5 �s 9hd oi 5f 2 c., <br />