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WELL/PUMP PERMIT SAN JOAQUD' 'NTY PUBLIC HEALTH SERVICES ENVIRONMENT EALTH DIVISION !, (/ 304 E, JER AVE,THIRD FLOOR STOCKTON CA 95202 k- -468-3420 VCD 1tlAn C7 h1tAkNON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS- �/`710 CAST �/019W]E'95—?5(2 �G= APN a 43"2l0- 1� CITY/ZIP R W./TC CSuA C %S ?3(2 PARCEL SIZE 'f/00 x y-std OWNER NAME �C� r rGM6 1ADDRESS S/1 P`L- f1s A f3yyt1 CITY/ZIP 5A MC AS A SoVIZ PHONE CONTRACTOR 1� � n��/��/� -ADDRESS 30 x 1-//40 CITY/ZIP !�� ` 4 9S��/ PHONE �Il� 7/� Y�00 C-57 LICENSE#7 o9C EXP DATE GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# MOTHER INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL#---, TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# 19 SOIL BORING ,�,-Pr4�bE ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIF.IC/A^TI N ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA~ A CONDUCTOR CASING DIA'1/1T ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE rJIA WELL CASING DIA ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH 1d' SPECIFICf TION 13IRRIGATION/AG OTHER GROUT BRAND NAME ?0 I;�Iµ-a ❑MONITORING GROUT SEAL PUMPED: ❑YES j(NO ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO APPROXIMATE WELL DEPTH /-x rE tj G PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER X I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY C-57 LICENSE IS CURRE\T AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKM.N,S COMPENSATION LAWS. I MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED��`4s�J 1 4 TITLE &-"LOS 1 S'T DATE '�O z D ART E T St ON Application Accepted By ��, —Date 14 Area EMPID# Grout Inspection By ate Pump Inspected By Date Destruction Inspection By Date COMME S: r p r K r PE SC AMOU CHECK#/ R NED D E PERMIT/SER ICER UEST# INVOICE#44t - WELL CODES INFO REMITTED CASH Z qa 8 .0 323 0a