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7 <br /> WELU/PUMP PERMIT = � _ !;�n ! <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEAL , C IVI'S'ION.r_ <br /> >� 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)4G8 3 1� �� 4� �� - <br /> + �,� cap :.._ .. <br /> NON-RFFUNDAD PERM T EXPIRES 1 YEAR FRONT DATE ISSUED <br /> JOB ADDRESS Z-SrD LV W 4-U 'L- __ APN O <br /> CITY/2!P �-��_ --_--- -PARCEL SIZE <br /> j <br /> OWNER NAME. � A� }�f� ADDRESS �C <br /> CI11 fZIP � PHONE l <br /> CONTRACTOR_I�1al+ "� LQ --- -ADDRESSZ� pZ� - <br /> - <br /> _ lHI.7�Ji Z �� <br /> CITYIZIP 7 7�GnJ �7 �7-C PHONE '44t ""--- �r`� G57 LICENSE# r ft?�_�5_ZEXP DATE ! <br /> GEOGRAPHICAL INFORMATION: COORDINA'T'ES X Y TOWNSHIP RANGE SECTION <br /> TYPE.OF WFLI.: ❑ NEW WELL El RFPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW AGEOTECHNICAL <br /> ❑ REPAIR H.N. DEPTH PUNIPSET FT. FIRST WATER LEVEL❑OUT-OF-SERVICE WELL # ❑SOILBORING ❑DESTRUCTION: <br /> INTENDEDI7SF TYPE )LL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM 410K EXCAVATION DLA r ` CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACKISIZE WELL CASING TYPE WELL CASING DIA <br /> Cl PUBLICJMUNICIPAL ❑DRIVEN GROUT SEAL DEF'i'H SPECIFICATION <br /> ❑IRRIGATIONIAG OTHER GROUT BRAND NAME IF i AJ Lsr <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> t <br /> APPROXIMATE DEP-1-H— - 5 <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY ALR ROTARY AUGER.CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED]THIS APPLICATION ANTI THAT THE WORK WILL HE DONE INACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,§jATE LAWS,AND RULES AND RF,GULATIONS. I ALSO CERTIFY THAT MY C-57 LICENSE 1S CURRENT <br /> AND AC'T IYE WITH THE CALIFO CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKNIAN'S <br /> COMPENSATION LAWS. <br /> Ul11 I(IC;R ADVANCE,NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED - �' - TITLESTA t ke'i 51O r-C­ DATE <br /> - <br /> _41 <br /> 3 t, - - �• r- S __ �� � rrear� I __ <br /> t• r' <br /> �•� `�,', <br /> O 1.4 ic <br /> , .w. <br /> 74 <br /> i .�,`1 j i MYBIBL�Bb S LO-094 <br /> L6 rMNM <br /> lO <br /> �EI_ <br /> A 3111 p _ <br /> I <br /> __� <br /> DEPAR'T'MENT USE ONLY <br /> Application Accepted By Z-4 �J _--D-ate Area z EMPID#7 <br /> Grout Inspection By Date P mp Inspected By — Date <br /> �7�yy <br /> Destruction Inspection By _ - Date <br /> COMMENT � VV t v"S [S` <br /> FE SC AMOUNT HECK RECEIVED DATE RMIT/SERVICE REQUEST# INVOICE# WELL 1D# <br /> CODES INFO REMITTED BY <br /> 3 l'No 2 I +42_- 3 coir '� l <br />