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i <br /> WELL TUMP 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 /> ON-REFUNDABLE PERMrT EXPIRES 1 R FROM DATE ISSUED (1 i <br /> TOB ADDR S n - / APN O5I _1 I Zv r— <br /> CTfY/ZIP r �. PARCELSIZE 15 acre <br /> OWNER :AM ADDRESS / <br /> r / _ <br /> CITY/Z , PHONE `�— <br /> CONTRACTOR , <br /> DRESS�!� ,. <br /> r' I PHO# N!. <br /> CITY/Z � �_V <br /> C-57 LICENS XP UATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y_TOWNSHIP_ RANGE_SECTION <br /> TYPE OF WELL: 0 NEW WELL ❑ REPLACEMENT WELL O MONITORING WELL# M OTHER <br /> INSTALLATION: O WELL SYSTEM REPAIR 0 CRO_SS-CONNECT REPAIR O VAPOR EXTRACTION WELL k <br /> NEW'{/,J��n/ H�.P. E P MP ET FIRST WATER LEVEL -- <br /> UTO ERVICE LL' ❑GGI HNICAL0 so 0 0DESTRU(.TION: <br /> nTE"EDUS TYPE OF WEL] CONSIR T T10NSPECIFI CATION <br /> ❑INDUSTRIAL O OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE OGRAVELPACK/SUE_ WELL CASING TYPE WELL CASING DIA <br /> 0PUBLTC/MUNICIPAL 11 DRIVEN GROUTSEALDEPTH SPECIFICATION <br /> O IRRIGATKXV/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: O YES D NO <br /> O CHRISTI'BOX O STOVE PIPE CONCRETE PEDESTAL BY DRILLER: O YES ❑NO <br /> APPROXIMATE WELL DEP H <br /> PROPOSED CONSTRUCTION/DRILLING METHOD:MUD ROTARY_AIR ROTARY_AUGER_CABLE OTHER <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED 171US APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANI)REGULATIONS.1 ALSO CERTIFY THAT MY C-57 LICENSE IS CURRENT <br /> AND ACTIVE 1VIITi THE CALIFORNIA CONTRACTORS STATE LI:,ENSF,BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S -p <br /> COMPENSATION LAWS. 6-1 <br /> INI Al 4 HOUR ADVANCE NOTICE REWIRED FOR INSPECT ONS Z <br /> SKiNE TTTLE <br /> r' <br /> _44— <br /> O <br /> — G <br /> I <br /> Iii <br /> m <br /> E — r <br /> 14 <br /> b <br /> Jill <br /> tStA <br /> n�� DEPARTMENI'USE ONLY ''((�� <br /> Application Accepted By Taij Ct, Date - �"� A._aLl EMP 4s <br /> Grout Inspectiaa DY—Date—Pump[lisp ed By r• _ ��y9� <br /> Ocstrucuon Inspection By Date <br /> COMMENTS: <br /> PE SC AMOUNT HECK#/ RECEIVED DATE PERMIr/SHRVICEREQUEST# INVOICE# WELLID# <br /> CODES INFO I REMITTED BY <br /> 0 5 50 1113 -5/-go-16 24 5R002 S a3� <br />