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WELL/PUMP PERMIT <br /> 1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 <br /> N! NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS_10�,04 Ll-j*�3+s EcC J APN 3 I 2-o Y <br /> CITY/ZIP 'r'24,, 1 s PARCEL SIZE 33 <br /> OWNER NAME SC-C, C.C13G =:T ADDRESS S-11k+n,-t <br /> CITY/ZIP PHONE Z C61- <br /> CONTRACTOR W U--, L A�y�ti v ata � Qt�� ADDRESS <br /> CITY/ZIP L.Ota1 Cs D1 °1C',S PHONE 7Z! j 0 1 C-57 LICENSE# EXP DATE 9&3 <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION 111111 <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 PUvIP SET FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# XSOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <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 0 'T: <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER A_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 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 I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> INIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED �/ TITLE DATE <br /> � • DATE Z <br /> S i <br /> _1 - <br /> s <br /> -)I ILily <br /> s, € <br /> n_Mitt <br /> Eiu fir LMJsER Icy <br /> ✓ C L DIV SI(' <br /> 4 <br /> DEPARTMENT USE ONLY ,( <br /> Application Accepted By Date, z'- Area r'� 4 <br /> EMPID# <br /> Grout Inspection By Dat Pump Inspected By Date <br /> 1y <br /> Destruction InrpecionBy DateMCO <br /> PE SC AMOUNT RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL ID# <br /> CODES INFO REMITTED CASH BY <br />