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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PUMP <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (2D9)468.3420 <br /> NON-REFUNDABLE PERMIT'EXPIRES I YEAR FROM DATE M-UED <br /> JOB ADDRESS 'L ct31 S. LCthAPN �� S�3 301 S� <br /> CrrYrz.IP Tr o,C--�v 9S3.7(p PARCELSME <br /> OWNER NAME---Tony�..cti. ADDRESS <br /> CITY/IJP_ PHONE -97j S— (et4 <br /> W e St oo�st��;yh rs <br /> CONTRACTOR.. Xj:l:S F\Qt L - ADDRESS 4) O l3 ox llp <br /> CrrY/ZIP_ V�c r-s+G— Gi53 p1-i PHONE!L7O5) g 35- "iB 14 C•57 LICENSEII _EXP DATE__ <br /> GEOGRAPHICAL INYGRMATION: COORDINATES X,__ Y TOWNSHIP_ RANGE_SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# _❑OTHER <br /> INSTALLATION: I.7 WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR O VAPOR EXTRACTION WELL# �- <br /> TYPE OF PUMP. M NEW ❑REPAIR H.P. Z DEPTH PUMP SE'r Fr. EIRST WATER LEVEL H <br /> ❑OUT-OP•SERVICE WELL ❑GEOTECHNICAL* ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE -uT OF .I.- CONSTRUCTION SPECIIICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA,_ <br /> N<MESTICPRIVATE ❑GRAVEL PACKISIZE WELL CASING TYPE WEiLCASINGDIA <br /> ❑PIIBLICIMUNICIPAL ❑DRIVEII GROIIT'SEALDEi'ITI SPECIFICATION <br /> ❑IRRIGATIONIAG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER. ❑YES ❑NO <br /> APPROXIMATE WELL DEFM %Lk <br /> PROPOSED CONSTRUCTIONIDR[LLING METHOD. MUD ROTAR Y—.AIR ROTARY -ANGER_CA BLE OTHER <br /> 1 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. 1 ALSO CERTIFY THAT MY C-51 LICENSE:IS CURRENT <br /> AND ACTIVE WITH THE CALIFORNIA CONTRACI.OR.S STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPEM"ATION LAWS. <br /> MINIMUM1 24 HOUR ADVANCE NOTICE,REQUIRED FOR INSPECTIONS <br /> SIr3NED � TTIE �yfnp TLCEI DATE <br /> 1 � - <br /> t <br /> «. - - <br /> DEPARTNEINT USE ONLY p <br /> Appl=Uoo Acccptecl Ry G_ Iq Ates EMPID#?�Oy <br /> Gmut lospectim Jiy_ DetcPump Inspected By ` - <br /> Desttucuon Impection By—_,__ ._ Dole <br /> COMMEM(B: <br /> PE SC AMOUNT CHEC'K#/ RECEIVED DATE PERFIITl1FLlCEREQUEST M WVOICEM WELL DO <br /> CODES INFO REMITTED .ASH RY <br /> De133i dr Z z a <br />