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J,Ln <br /> 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 /> LE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 5, ( r l uVF� �r <br /> JOB ADDRESS E Ck� 4S `i /fir �j•�.' 1` r�LD " e� I <br /> �( <br /> G `'1 IIICIa APIC_ <br /> CITY/PIP S C '� r ?.;(. .� PARCEL SIZE �" I ` <br /> OWNER NAME G-W- I _-ADDRESS ���'� i?C sx J Gl1 L]'�I <br /> CITYILIY 7�C IU+� 1 S7V , <br /> L— .. PHONE f _ <br /> CONTRACTOR,Ccd kev rr��GCUe .h� `(:1i It'Oil"&DDRES\S_ _ Cf'l, 'rS ry! o. JSZq <br /> CPi'Y/Z1P �ZV �� 'r tel_-_ -747- PHONE1O) � 24't2707 -.—C-57 LICENSE#'7L&�4LEXP DATE <br /> GEOGRAPHICAL I`NF'GRMATION: COORDINATES X Y _ TOWNSHIP RANGE: SECTION <br /> TYPE OF WELL: 1 NEWWELL ❑ REPLACEM1rNT WELL ❑ MON!TORiNG WELL#,- 0 OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR I]CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# _ <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H-P. DEPTH/PUMP SET FT. FIRST'WATER LEVEL <br /> pb <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL SOIL BORING licl'"► S ❑DESTRUCTION: <br /> INTENDED USE TYPE:OF WELL CONSTRUCTION SPECIFICATION ;'y <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DLA CONDUCTOR CASING DIA _ <br /> r <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL. CASING TYPE WELL CASING DIA �- <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> l'-.. <br /> ❑IRRIGATION/AG OTHER GROU'S'BRAND NAME <br /> ❑MONITORING GROUT SEAL PLUMPED: ❑YES ❑NO <br /> .i <br /> ❑CHRISTY BOX ❑STOVE PIPE 11 CONCRETE PEDESTAL BY DRILLER- ❑YES ❑NO <br /> APPROXIMATE WELL DEPTH 1 Pee <br /> POSED <br /> PRO CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGERf CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TIIE WORK WILL BE DONE IN ACCORDANCE WI'T'H SAN <br /> ICIAQUIN COUN'T'Y ORDINANCES,STATE LAWS,AND RULE'S AVD REGULATIONS. I ALSO CERTIFY THAT MY C-57 LICENSE IS CURRENT <br /> AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICEN`iE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> �} IU. �a OUR :+j�V;1NCI �,bTLCI. l�l�QLJ1RED FOR INSPECTIONS <br /> SIGNED -TITLF &7AFF 6u& -uLrE K. ___DATE <br /> I i <br /> Y' 11 I I <br /> t <br /> J <br /> I ' <br /> pip , <br /> C <br /> . - <br /> f f' rc7 <br /> DEPAR'L'MENT USF ONLY I <br /> i y <br /> Application Accepted.By ~Z �� Date Area -EMP1D# ?� <br /> Grout Inspection By -- Date Pump Inspected By __Date <br /> Destruction Ifi.pcc <br /> lion By G _ .—Date_ —0/�3 <br /> COMMENTS:_ <br /> PE SC AMOUNT CHECW RECEIVED DATE PBRMTT/SERVICE REQUEST# INVOICE# WELL ID# <br /> CODES INF:) REMITTED H BY <br />