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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 /> ' n Q NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED "� <br /> JOB ADDRESS lJ� I E � Z /�Q <br /> APNy ' I (Dr <br /> CITY/ZIP Lt n yP�n J a I ,p 1 Z 3(O BOY, <br /> PARCEL SIZE �,[�18 C .�j <br /> OWNER NAME �n t 1 a!M I-DVe-I ADDRESS FO BOY\ IQ . U nde n �.� 1 q v 2-J`, <br /> CITY/ZIP PHONE <br /> CONTRACTOR C] ADDRESS <br /> CrIY/ZIP PHONE C-57 LICENSE# EXP DATE_ <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER _ <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING XDESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DLA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑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 /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANQES,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 I AM IN COMPLIANCE WITH ALL WORI4MAN'S <br /> COMPENSATION LAWS. <br /> MIN MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLEDATE-7—­5_01 <br /> V <br /> f <br /> , s <br /> JG; <br /> AL HS t JAI 'r <br /> -AI TH <br /> DEPARTMENT USE ONLY 11(v 41f y <br /> Application Accepted By Date �^ / Area // EMt'I <br /> Grout Inspection By to N Pump Inspected By q C Date <br /> Destruction Inspection B Date <br /> COMMENTS: �' Yy dei -WeAj- To $E I L-5Z b '.Xt l <br /> PE SC AMOUNT CHEC RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL ID# <br /> CODES INFO REMIT'T'ED BY <br /> q3 73 /(g/ wo41w� 10395 C,,G .-71q a 9� � <br />