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WELLIPUMP PERMIT -) q 6 <br />SAN JOAQuIN COUNTY PUBLK' HEALTH SERVICES ENVIRONMENTAL HEALTH DMS( 1 <br />304 E. WEBER AVE, THIRD FLOOR STOCKTON CA 95202 (209) 468-3420 <br />rr NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED �. �� <br />JOB ADDRESS_,_ i 5b In f--�r[L"*i I nS, ZrIL APN <br />CITY/LIP :Tr C- r- .1 0 A, SIZE <br />OWNER NAME -TI C,, x t IIP ADDRESS05 S rJ Q CYa r"tx.l'Yfi t r'v c+ Z_cl <br />CITY2.1P _fir 4 c �F L'. A , g �j–/3 T (c PHONE <br />C'.ONTRACTOR --�-7rCltr S I-lerlflnc CLJeSt ADDRESS ISO hr,x Iio <br />CTTY26 Gf5 tt` S �pHONE h�--_Z��'4 C-57 LICENSE# _EXP DATE <br />GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP_ RANGE_ SECTION <br />TYPE OF WELL: ❑ANEW WELL, ❑ REPLACEMENT WELL. C3 MONITORING WELL p _ ❑ OTHER _ <br />INSTALLATION: H WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL If <br />TYPE OF PUMP: I'NEW ❑ REPAIR H.P. I 5 DEPTH PUMP SET � ._PT FIRST WATER LEVEL <br />❑ Ot.T-OF-SERVICE WELL ❑ GF.OTECHNICALM .___ ❑ SOIL BORING O DESTRUCTION: <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECI'r (CATION <br />❑ INDUSTRIAL ❑ OPEN BOTTOM WELL EXCAVATION IIIA CONDUCTOR CASING DLA <br />frDOMESTICPRIVATE ❑GRAVEL PACKISI7E WELL CASING TYPE WELL CASING DIA <br />❑ PLBL1GMUNiCIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br />❑ IRRIGATION/AG OTHER GROUT BRAND NAME <br />❑ MONITORING GROUT SEAL PUMPED: ❑ YES ❑ NO <br />❑ CHRISTY BOX ❑ STOVE PIPE CONCP.EIE PEDESTAL BY DRILLER: ❑ YES ❑ NO <br />APPROXIMATE WELL DEPTH :3�Z <br />PROPOSED CONSTRUCTION/DRILI.MGMETHOD: MUDROTARY AIRR(7t'ARY_--AUGER CABLE_ OTHER <br />I HEREBY CERTIFY TIIAT 1 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 1 <br />AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKMAN'S <br />COMPENRATION LAWS. <br />/ MINIMUM 24 HOUR ADVANCE: NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED �` r TTI1E Amp leG{L DATE <br />- I <br />- - <br />fqt <br />t <br />DEPARTMF,NT USENLV <br />-.. <br />Application AcceptaJ By -__ <- _ _..__ EMPfl)#.LL-- <br />Grout inspection By__... - Date Pump Inspected By <br />Destruction Ir_spection By Date <br />COMMENTS; <br />PP. SC AMOUNT HECK#/ RECEIVED DATE PP.RMITISERVICEREQUEST# INVOICE# WEiLID# <br />CODES INFO REMITTED BY <br />f �� o a3 ire G <br />a <br />