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n <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> Ca 'Tr J 304 E WEBER AVE,THIRD FLOOR STOCKTON CAA 952.42 (209)468-3420 r <br /> [Q I`I I e ►1,`AB W. A�iiREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS R , <br /> CITY/ZIP _ PARCEL SIZE <br /> OWNERNAME ��t/_�T-�5�, ADDR15 <br /> CII'YlLIP +'+j <br /> CONTRACTORA45Ej ( p,A tI967tt ) 1,&K&C-'ADDRESS �LZ l S l'� L-14 <br /> S� <br /> PHONE�Z. 3 -7-74p' C-57LICENSE#6l44XPDATE1 , ��s <br /> GEOGRAPHICAL INFORMATION., COORDINATES X i',_ /T/OWNSHIP . RANGE-- SECTION <br /> TYPEOF WELL: ❑ NEW WELL 1:1 REPLACEMENTWEI,L, Cr, 4Nr1PrdtW # _D OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# J <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DL fH PUMPSET1 7'. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING 13 DESTRUCTION: <br /> INTENDED LINE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA-- <br /> I I <br /> IA _II <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SI7.E WELL CASING TYPEALe2 #'2 WELL CASING DIA _ �t <br /> ❑PUBLICIMUNICIPAL ❑DRIVEN GROUT SEAL DE!`TH 5� SPECIFICATION (TI <br /> ❑ IRRIGATION/AG OTHER GROUT BRANDNAME'TYIF:C�= f JJ2MUAM;'� <br /> :5 e.-Al <br /> K <br /> MONITORING GROUT SEAL PUMPED: ❑ YES FNO <br /> /////❑CHRISTY BOX ❑STOVE PIPE 'Q f CONCRETE PEDESTAL BY DRILLF-R: ❑YES C N0 LTJ <br /> APPROXIMATE WELL DEPTH <br /> ? <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER X—CABLE CYPHER S- <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE HONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND RECULATIONS. I ALSO CERTIFY THAT MY C-57 LICENSE IS CURRENT <br /> AND ACTIVE WITH TUF:CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> — COMPENSATION LAWS. I L <br /> 14IIhlN N �Ilf]C1k A1)1':1 V('1: �►,OTI{'H;Kla_ I!IfRED 1'()R 1VS1'Ff"C1i7NS <br /> SIGNED r✓'` T'ITI _ t Yr+ �1� �l i^x C��' DATE-77r� - <br /> 1# <br /> 7 <br /> `p <br /> 71 <br /> — ,— <br /> ~1 <br /> S _ <br /> ..-41'•a >'i _- ,a <br /> oil <br /> f„'.i�i t •fit - <br /> 2� ,-_ <br /> Woe <br /> J_ <br /> -Ir, „ — <br /> E <br /> 1�1 r DEPARTMENT USE ONLY <br /> Application Accepted By_-._ , �' "`�� � Date _Area �+ -Em PID# �(j, <br /> Grout Inspection lay_ Date_ --Pump Inspected By �j `Date <br /> Destruction Inspection By Date / <br /> r i <br /> COMMENTS:- "q 80Rtuss <br /> -- <br /> PE Sc AMOUNT 2CjLELjW RECEIVED DATE, ! EfMATI'11SERVICE REQUEST# INVOICE# WELL BD# <br /> CODES INFO REMITTED CASII BY <br /> -3 -7`I5 <br />