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r <br /> WELU/PUMP PERMIT <br /> SANJOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PUMP <br /> 304 E.WEBER AVE,THIRD FIAOR STOCBTON CA 95102 (209)468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I Y AR FROM DATE LSSUED <br /> JOB ADD ESS -px CJ _ I -IZ O I <br /> CITY2lP Ir 15• ov <br /> PARCEL S <br /> OWNERAM ADDRES <br /> 1T <br /> CYfI1P�-1 J t <br /> PHONE( 34"I 05 <br /> CONTRACTOR— DDRES� <br /> i CITY(Ip ��! L "7 � I'HONfz !' I. Y J G 51 LICENS> DATE- <br /> t <br /> GEOGRAPHICAL INFORMATION: COORDINATES XK_ y_TOWNSHIP._.- RANGE_SECTION <br /> TYPE OF WELL: D NEW WELL R REPLACEMENT WELL D MON O.ORINGWELL# <br /> 13 OTHER <br /> INSTALLATION: O WEU.SYSTEM REPAIR D CROSS�CONNEXT REPAIR L7 VAPOR EWRACCION WELLM <br /> TYPE OF PUMP, Y NEW D REPAIR H.P.—fa— DEPTH PUMP SET PT. FIRST WATER LEVEL —_ <br /> D OUT-OF-SERVICE WELL 0 GFXYMCHNICAL Y Q SOIL BORING ❑DESTRUCTION: <br /> NL LADED USE TYPE OF WPLI CONSTRuCTjO�Y S�_IF'ICATION <br /> D INDUSTRIAL Q OPEN BOTIOM WELL EXCAVATION DIA________ CONDUCTOR CASING DU <br /> I3 DOMESTIC PRIVATE ❑GRAVEL PACK/S12E_ WF.l1 CASING TYPE WELL CASINGD(A <br /> I3 PUBLWJMUNICIPAL 13DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ILRIGATH)N/AG OTHER GROUT HRAND NAME <br /> O MONITORING OROUT SRAL PUMPFD: ❑YES D NO <br /> D CHRISTY BOX D STOVE PIPE CONCRFUM PEDESTAL BY DRUER: D YES D NO <br /> APPROXIMATE WELLDEP7[d�— <br /> PROPOSED CONSTRUC•RON/DRILLINO METHOD:MUD ROTARY—AIR ROTARY_AUGER_CABLE„„ OTHER <br /> I HEREBY CERTIFY TIIAT I HAVE PR$PARED 71IIS APPLICATION AND THAT THE WORK WILL HE DONE INACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGIILATIONS.I ALSO CERTIFY THAT MY C47 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 /> �ffNWUMNHOUR DVANCENOTICE REQUIRED FOR INSPECTIONSSIGN <br /> W____ - E —. -_ ———— <br /> - Z <br /> �-- 4 - , <br /> f 44 <br /> i <br /> � DEPART USE ONLY <br /> Application Accepted By_ /` �L�"�f,6� Date prca_ �I. EINPIiNI LA,J� <br /> Grout Inspection P.Y Date P■mp Inspected B <br /> Destruction lnspecti m By to <br /> COMMENTS: <br /> PE SC AMOUNT CHEC RECEIVED RATE QUEST X INVOICE 0 WELL NB <br /> j <br /> CODES <br /> REMITTED CASH BY <br /> ' 380 65a Sb ,l o Sit a�.��s-�y 33 <br />