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WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ° 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 NON-REFUNDAB E PERMIT E IRES 1 YEAR FROM DATE ISSUED �^ J JOB ADDRESS pp ) APN CTTY/ZIP V`0 61 PARCEL SIZE c2 -7 ` v-=�, OWNER NAME I � (20 Z*1 n ADDRESS CITYIZIP �k c, r7 1 PHONE 516 /c -> CONTRACTOR Ay X72 ►^ f t,.�L 6e ADDRESS CITY/ZIP PHONE C-57 LICENSE# EXP DATE GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONTI'ORING WELL# ❑OTHER 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# ❑SOIL BORING ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELL CASING DIA ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION ❑B2RIGATION/AG OTHER GROUT BRAND NAME ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO APPROXIMATE WELL DEPTH PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER ^^j I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN eJ JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY C-57 LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S COMPENSATION LAWS. MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS SIGNED TITLE DATE n� S DEPARTMENT USE ONLY Application Accepted By •� n1' Date Area 2�� EMPID# If Grout Inspection By Date Pump Inspected By Date Destruction Inspection By Date COMMENTS: PE SC AMOUNT CHECK#/ RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL ID# CODES INFO REM CASH BY