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WELUPUMP 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 /> �f YNON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f 32-,C �l q <br /> JOD ADDRESS / `t C ,�j� APN I �f —V�> 1 <br /> CTTYl,Z'IP PARCEL SIZE [/!/ I V <br /> OWNER NAME - ADDRESS <br /> CTTY/ZIP___" PHONE <br /> CONTRACTOR - ADDRESS <br /> C1TYlZIPe PHONE ?—' SS4� C•57 LICENS �EXP DA� <br /> GEOGRAPHICAL INFCIRMATION: COORDINATES X_._ Y TOWNSHIP RANGE 2ESECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL M ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL A <br /> TYPE OF PUMP: ❑ NEW REPAIR H,P.— ,10� DEPTI[ PUmP SET�j,��FrT. FTR.S`T WATER IIL��,,E[[VEL <br /> ❑OU-T-OF-SERVICE WELL ❑GEOTECHNICAL* _ 11 SOIL RORING ❑DESTRUCTA44 ' `L <br /> RfMND.ED USE TYPE OF WELL CONSTRUrTIONSPECPFICATION r;i.h a.' . . <br /> DUSTRIAL OPEN BOTTOM WELL EXCAVATION DLA_ '�f1N1F��7F F`OR CASWG'b1A <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLICIMUNICIPAL ❑DRIVEN GROUT SEAL DEPTH w SPECIFICATION <br /> O IRRIGATION/AG OTHER GROU-f BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑ YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL HY DRILLER: ❑ YES ❑NO <br /> APPROX.DIATE WELLDEP'IH_ <br /> PROPOSED CONSTRUCTION/DRB.—WG METHOD: MILD 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 CALEFOR'VIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WM ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> MlNlh 24 HOUR ADVANCE: NOTICE RF,QU RED FOR INSPECTIONS <br /> SIGNED _TTTI_E DATE �Q <br /> Ar <br /> 1RAI <br /> DEPARTMENT USE ONLY <br /> Application Acccptea By Date Areae-.,ED#� <br /> Grout Inspection By__. Date Pump Inspected By y' ��5�/ _Date �v <br /> Destruction Ir.spection By flare <br /> COMMENT'S: <br /> PE Sc AMOUNT CHECK#t RECEIVED DATE P I'T/SERVICE REQUEST*,,, INVOICE Y WEd,ID1t <br /> CnDE.S INFO REMTT-IED CASH Y <br /> fjYn G56 5a r5U RJO �+20b X34 av� <br />