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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 />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 5 7 jet' ,-/ Do ratio APN `76---125-1 <br />CITY/ZIP `3)-774- 70 '-, PARCEL SIZE 9. <br />OWNER NAME iga , 4- el/ -5iCie- 1-C" ADDRESS /e)° /304- //AO' <br />CITY/ZIP ..?-- et e. f I-6'21 PHONE <br />CONTRACTOR 1e)e57 - A r 2..4.f a- / ADDRESS 3 02 .2 7 177,7 c y- e fr q I .-4 * " - , -0fi , <br />CITY/ZIP /Pe..e si t 4e Go r4'4 PHONE 5?/6 635-- 702 76, C-57 LICENSE# --lie EXP DATE <br />3 7, 7/05 / 2/02 7 ',?2- . GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br />TYPE OF WELL: 0 NEW WELL 0 REPLACEMENT WELL 0 MONITORING WELL # 0\OTHER <br />INSTALLATION: 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL # <br />TYPE OF PUMP: 0 NEW 0 REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br />0 OUT-OF-SERVICE WELL 0 GEOTECHNICAL # 0 SOIL BORING 0 DESTRUCTION: <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br />0 INDUSTRIAL 0 OPEN BOTTOM WELL EXCAVATION DLL // CONDUCTOR CASING DIA01 <br />0 DOMESTIC PRIVATE 94GRAVEL PACK/SIZE ' -4.: WELL CASING TYPE ill e - WELL CASING DIA -27* <br />CI PUBLIC/MUNICIPAL 0 DRIVEN GROUT SEAL DEPTH SPECIFICATION <br />0 IRRIGATION/AG OTHER GROUT BRAND NAME <br />0 MONITORING GROUT SEAL PUMPED: 0 YES NO <br />0 CHRISTY BOX 0 STOVE PIPE CONCRETE PEDESTAL BY DRILLER: , 0 YES 0 NO <br />APPROXIMATE WELL DEPTH 1.,; I <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER '<I 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 />M MUM 24 HOUR A ANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNE TITLE GO -II it/ /1-0 -61 i DATE or-is <br />111111 11111111111 I Ill II <br />1 IIuIIuIuIuuhuuIu MEN <br />MIMI I 1 . <br />li Ism I III <br />711,11MM) II IIuuuUuIIIIIIIuIIiIU!iIZ' <br />IW: <br />FA ICR11/ <br />!FIUME! <br />WI liliWMPIEPI <br />BRIIMEIREIRIENWFAZERMMMinariarillEIDZI E uII.uuuu <br /> <br />r El Ewe <br />, <br />I II 011111h11111111 Nall <br />G ' Iti <br />ir ' • / <br />DEPARTMENT USE ONLY <br />/* ../'( Application Accepted By Date/k1/0 X Area '977 -49,2- EMPID# qq7 <br />/-34//,^ Grout Inspection By t ---1-"t Date (71/51b3 Pump Inspected By Date <br />Destruction Inspection By Date <br />COMMENTS: Lot' 5de -Li,e-a-e...eA,-- e..# ..-e-- 3 -62 5. <br />PE <br />CODES <br />SC <br />INFO <br />AMOUNT <br />REMITTED <br />CH K#/ <br />CA <br />RECEIVED <br />BY <br />DATE PER A kl - INVOICE # WELL ID# <br />-- h-q 5/200 3Z-riq <br />\........,