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i <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH D[V,sW- E L L <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 <br /> f <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ?00 of S 1 O t PN A q— 12-6 ( I <br /> C1`Y/ZIP .ti <br /> PARCEL SIZE <br /> OWNERNAME <br /> V 1 5 �`J�.1 ISI' 1�c SG ADDRESS l�C� l �0 0-IL <br /> CPI'YPLlp_ 7 C11� V1 Gj�j Lt S '+L 2-—Z0 3,)-- <br /> PHONE T <br /> CONTRAC�/TOR�� ff ii ADDRESS <br /> v V\ 2- <br /> , 16 PHONE C-57 LICENSE# U'�r ""EXP DATE <br /> lam` r _ ?2-- <br /> GEOGRAPHICAL <br /> L <br /> GEOGRAPHICAL INFORMATION. COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# _13 OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP; ❑ NEW 13REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> XOUT-0F-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> ENDED USE TYPE OF WELL CONSTRUCTION SPECIFI�T <br /> 13 INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLICIMUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> E3IRRIGATION/AG <br /> OTHER GROU"i'BRAND NAME <br /> Cl MONITORING GROUT SEAL PUMPED: ❑YES 0 NO <br /> ❑CHRISTY BOX 11 STOVE PIPE CONCRETE PEDESTAL BY DRILLER: 0 YES ❑NO <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTION/DRILLING METHOD; MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HN <br /> ]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 1S 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 /> MINI =UM4 HOUR MWANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED <br /> TITLE DATE �)-0 21 <br /> e — — <br /> i <br /> i <br /> DEPARTMENT USE ONLY <br /> Application Accepted ply <br /> Date /0) Area ;? _ EMPID# <br /> Grout Inspection By <br /> Date Pump Inspected By <br /> —_Date <br /> 1 -�S Destmction Inspection B _ Date _ <br /> 1f� <br /> COMMENTS;_ H k C Z — � <br /> PE SC AMOUNT CHECK#/ REC ED DA PERMIT/SERVI EREQUEST# INV ICE# WELL.ID# <br /> 5` CODES INFO REMITTED BY <br /> 42- '3(2,0of ti <br /> 0"-e cpe roc , r..LZ4 s�c�, -e' <br />