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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVrES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)4683420 <br /> NON•REFUNDA�iLE PER UT EXPIIRRES/I YEAR FROM DATE ISSUED <br /> ��p <br /> IOBADDRESS,_ 2�7 _�, C`(�ry�Pf' /�/t APN `39 L <br /> EA <br /> CII'Yri1' S U _ ARCELSIZF <br /> OWN8R N.AM6 Ahr- /0C/&DDDRESS__10�7 V_VIA 4`V <br /> Cryan,��s_ L.C�•N PHONE <br /> CONTRACCOR_ ADDRL•SS ..— <br /> CITY/LIP PHO\E C-57UCENSE7t __EXP DATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y_TOWNSH1P_ RANGE—SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WEIJ.k ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL k <br /> TYPE OF PUMP. ❑ NEW d REPAIR H.P. DEPTH PUMP SET FT. FIRST'WATER LEVEL <br /> )(OUT-OF-SERVICE WELL ❑GEOTECHNICAL k ❑SOH.BORING __ ❑DESTRUCTION: <br /> INTENDED US TYPE OF WT:LI. CONSTRUCTION SPECIFICATION <br /> O INDUSTRIAL ❑OPEN BOTTOM W'FIJ,EXCAVATION DSA CONDUCTOR CASING UTA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACKISILE WELL CASING TYPE WEL LCASING DIA <br /> ❑PUBLICIMUNICIPAL ❑DRIVEN GROUT SEAL DE!'I11 SPECIFICATION <br /> ❑IRRIOATION/AG OTHER GROUT BRAND NAME-----, <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELLDEP114 1.20 <br /> PROPOSED CONSTRUCTION/DRI.LING METILOD: MUD ROTARY AIR RC7TARY AUGER—CABLE. _OTHER k3l1 <br /> I HEREBY CEKn Y THAT I HAVE'PREPARED THIS APPLICATION AND TIL1T THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN C.OU INANCES,. LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY C-57 LICENSE IS CURRENT <br /> ANDA TTH CALWO IA CO CTORS STATE LICENSE BOARD AND THAT I AMIN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> A11 IMLIM t10 VANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SI NED l'm.E _ DATE /O /_0J, <br /> I <br /> i <br /> DEPARTMENTUSFONLY <br /> Applicatim Accepted By' Date f <br /> 1 Arca '-�2, EMPITIri <br /> Caput Inapecuutt By --Date_ -.---Pump Inspected By <br /> Desaucuon Inspection By �7 �'t /� �j—7 mate -_ <br /> COMMBNTS: HR lace ^ ,PJI9�Q()I lJ Z12,01!-2(1ei-In <br /> lie 1l 5e"I d,e- <br /> r.'E Sc AMOUNT 1LUECKWI RECEIVED DATE IT/SERVICERFQUE If INVOICE WELLID0 <br /> CODES INA) REMITTED CASH BY <br />