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f � - WELL/PUMP PERMIT US� 30Lu <br /> SAN JQAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIV 15[ON OA 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 <br /> NON-IZN�FUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS AV1 /�/-l�f, n J,� APN E}I <br /> CiTYrLIP [ 0 Z v✓/ <br /> 1 A�EL SIZE <br /> OWNER NAME � Q � ADDRESS �.. I{I <br /> CITY/ZIY J e ffl/)—I F <br /> CONTRACTOR <br /> - Cl— � _L../106-14 ,_ . ADDRESS <br /> CITYfLIP `(C�I�/� LtJLLl7 PHONE � <br /> „-_ 2� C-S7 L[CENSE# EXP DATE <br /> S l.� <br /> i <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> RD <br /> TYPE OF WELL: ❑ NEW WELL Iy REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER 1 <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# I <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET Fr. FIRST WATER LEVEL_Ao ` <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: I <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIE_I-CATIO / <br /> k <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA <br /> CONDUCTOR CASING DIA <br /> - 1 <br /> DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE S�` WELL CASING DIA <br /> r I <br /> 13PUBLICIMUNICIPAL ❑DRIVEN;„, GROUT SEAL DEPTH - <br /> SPECIFICATIONC <br /> �I 1i�' ii • iI `� - <br /> ❑IRRIGATIONIAG 'i: . OTHER GROUT BRAND NAME G✓ <br /> I <br /> ❑MONITORING OCT a i' 2001 GROUT SEAL PUMPED: uta ❑NO , <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑LYTag- ❑NO <br /> APPROXIMATE WELL DEPTHJill <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARYy AIR ROTARY AUGER CABLE OTHER p <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. I ALSO CERTIFY THAT MY C-57 LICENSE IS CURRENT !! <br /> AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> M I lJM 24 II)UR ADVANCI NOTICL RI?(}LfI ) ICOR INSIlECTIONS <br /> SIGNED TITLE 4L/f/! DATE <br /> i <br /> LIZ <br /> 0 >11F <br /> Lli <br /> I <br /> A. <br /> — I <br /> I <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Area EMPID# <br /> Grout Inspection By Date Pump Inspected By Date <br /> Destruction Inspection By Date <br /> COMMENTS: <br /> I <br /> PE SC AMOUNT CHECK#/ RECEIVED DATE PERM MISER VICE REQUEST# INVOICE# WELLIi7# <br /> CODES INFO REMi'-MD CASH BY <br />