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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 . ....„,..1 Li <br />JOB ADDRESS "" <br />, <br />"' 1-' -1 S - , c- a. C- o 47 } r:, , crelo APN ,,/ <br />CITY/ZIP Sr 'ire/ Oso -71 9f1 a a PARCEL SIZE / :).. a e.., <br />OWNER NAME ha "Pf 41 ( Ana •1/7ADDRESS .,•7 7 A/e7ilept, zr i)y, ce.",ige / 5-0 ./. .-1,/,-/7 . <br />CITY/ZIP v'7'-- 1-ae/iS tiD PHONE 6- :36 ‘, 5/- J 7' <br />CONTRACTOR Zcia/:;°k- Ilf a i/ 4- Pr, kis ADDRESS / 02a /40 Ye', = ' , A/e <br />CITY/ZIP 410 0 i k -I/ ei PHONE 52.e/ l://-"*" .."‘/•* C-57 LICENSE id if ' / t. EXP DATE <br />GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br />TYPE OF WELL: 0 NEW WELL 0 REPLACEMENT WELL 0 MONITORING WELL #OTHER L 3:9'1:;' e 1--, <br />11. e INSTALLATION: 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR a; VAPOR EXTRACTION WELL # <br />TYPE OF PUMP: 0 NEW 0 REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br />/ <br />0 OUT-OF-SERVICE WELL brGEOTECHNICAL # 0 SOIL BORING 0 DESTRUCTION: ., <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br />0 INDUSTRIAL 0 OPEN BOTTOM WELL EXCAVATION DwaX1CONDUCTOR CASING DIA AM <br />CI DOMESTIC PRIVATE CKORAVEL PACK/SIZEOP ( eigi' WELL CASING TYPE Ple/5794ELL CASING DIA <br />o PUBLIC/MUNICIPAL 0 DRIVEN GROUT SEAL DEPTH SPECIFICATION ( • • : <br />./ r Ie'rci / 44115 0 IRRIGATION/AG OTHER GROUT BRAND NAME c-ti A , 5 ,...4, X/6/91- f; <br />p/MONITORING etb(41^1 VA„Ve9 '2_ Iv r are re? 18 GROUT SEAL PUMPED: )DYES 0 NO <br />0 CHRISTY BOX 0 STOVE PIPE CONCRETE PEDESTAL BY DRILLER: 0 YES yl,K) <br /> <br />x) , i i. <br />- • <br />-- 4 - / APPROXIMATE WELL DEPTH ''" c," — ./ <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 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 />t I IVIVUM 24 HOUR VANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED ....--•' A TITLE /219 -'1 ) 5k,"7"0 ..., / DATE 7:2 Ve9-3 <br />, <br />19 ./e-4.../ 4-tie/Y5 , <br />, .. <br />A/ e /%% t"...,t ,' a., ke J e., 6 4.-leit <br />, <br />DEPARTMENT USE ONLY , <br />Application Accepted By /14614-4"“_ Date ;/ /0 3 Area? g 7/6 I EMPID# 99 7 <br />Grout Inspection By hikv,0-A-/( Date(//f 1,(0?Pump Inspected By Date <br />Destruction Inspection By Date <br />COMMENTS: 14)? 5 de ik S <br />PE <br />CODES <br />SC <br />INFO <br />AMOUNT <br />REMITTED <br />CHECK#/ <br />CASH <br />RECEIVED <br />BY <br />DATE PER UEST # INVOICE # WELL ID# <br />k: of eci -14*-- 3/ 33ii 540o ?? z,s- r <br />.‘,.... __.--