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WELL/PUMP 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 /> x <br /> NON-REFUNDAB E PERMIT E311RES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS J APN <br /> CITY/ZIP 1,0 PARCEL SIZE A(f <br /> OWNER NAME � 00 � � a n I ADDRESS R `i V - l�,� c, 4 � <br /> I � <br /> CITYIZIP !�h o O .1 PHONE 36 S <br /> 1 za 4' <br /> CONTRACTOR ('1v 6� r T ADDRESS <br /> CITYIZIP PHONE C-57 LICENSE# EXP DATE I <br /> I <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OT14ER ! <br /> I <br /> i <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# i <br /> TYPE OF PUMP: Q NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> I <br /> OUT-OF-SERVICE WELL El GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACKISIZE WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLICJMUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> I <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I <br /> I 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 IS CURRENT <br /> AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKMAN'S { <br /> COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS ' <br /> SIGNED �►rr TM-E DATE <br /> all <br /> w' <br /> cbr 6\ <br /> 2 I <br /> 1 � <br /> I.L-El r_ A <br /> EWIR01WEPTAt HEA T1 )1V14-0;, <br /> 1 <br /> \ DEPARTMENT USE ONLY y <br /> i <br /> Application Accepted By Date Area t' EMPID#_ 110 I <br /> Grout Inspection By Date Pump Inspected By Date <br /> i <br /> Destruction Inspection By Date <br /> COMMENTS: <br /> PE SC AMOUNT CHECKW RECEIVED DATE PERMITISERVICE REQUEST# INVOICE# WELL ID# <br /> CODES INFO REM CASH BY <br /> q3&q- 179i <br /> 1 <br />