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WELL/PUMP PERMIT <br /> SAN IOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 <br /> NON•RERUNDA LE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> !OB ADDRESS • > `` APN I/ t/OO O^Q� <br /> CRY/ZRP J' J3 o PARCEL SIZE <br /> OWNER NAME ADDRESS_ 2- n <br /> C1TY21P PHONE <br /> CONTRACTOR, ADDRESS2411 a g 2gor-s ;?��/ / , <br /> CII1lLIF ,/ PHONE--.92.5- <br /> HONE 9/�j!Z— C-57 LICE47mIi76 I-XPDA� 0 <br /> GEOGRAPHICAL INFORMATION:COORDINATES X__ Y_TOWNSHIP` RANGE_SECTION <br /> TYPE OF WELL: 9L NEW WELL ❑ REPLACEMENT WELL MONITORING WELL. _ZF30THER <br /> INSTALLATION: D WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL ar <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET PT, FIRST WATER LEVEL <br /> D OUT-OF-SERVICE WELL O GP.OTECHNICAL k ❑SOIL BORING Q DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CQNSTRLjMON SPECIIICATION - ^�1'• , <br /> D INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION Dlw � CONDU <br /> C�CASINGDIA <br /> ❑DOMESTIC PRIVATE GRAVEL PACKIS¢E_21& WELL CASING TYPE Pyc WELL CASING DIA L/' <br /> ❑PUBLICIMUNICI>AL ❑DRIVEN GROUT SEAL DFM—VV13SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME O 1 O <br /> MONITORING GROUT SEAL PUMPED: ❑YES 'IO <br /> D CHRIM BOX STOVE PIPE ,{( CONCRB-IT PEDESTAL BY DRIlER: Pr YES ❑NO <br /> APPROXIMATE WELL DEPTH—30 <br /> 0 �S <br /> PROPOSED CONSTRUCTTONIDRILING METHOD: MUD ROTARY_AIR ROTARY—AUGER—x CABLE,OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> IOAQUIN COUNTY ORDINANCES,STATE LA YD RULES A:ND REC,ULAT[ONS. I ALSO CEAT[PY THAT MY C-57 LICENSE 1S CURRENT <br /> ANDA WITH THE LWORNIA CONT RS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WrM ALL WORKMAN'S <br /> COMPEMSATION LAWS. <br /> U 24 E 111 ADVANCE NOTICE REQU(IIRREyDL FOR INSPECTIONS �C <br /> SIGNED TILE AR• DATE v O <br /> t � 1�O.�b•" I [ <br /> w 3}I <br /> D ARTMENT USE ONLY <br /> Application Accepted By / Date JCA/� A[r2 —EMPDM _ <br /> Grout laspecum Ta Da I 4�Pump Inspected By _pate <br /> Destruction Iuspectioo By tc <br /> COMMENTS: 3Q <br /> 00, <br /> YE SC AMOUNT ECK RECEIVED DATE PERMITISERVICEE INVOICE k WEL.I.m1R <br /> CODES INFO REMITTED CASH BY <br /> S2, ao I lit p <br />