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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 93202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> J013ADDRFSS_19530 11. GRANTLIWE RD. APN 209-070-23 <br /> Crrv[zIP TRACY PARCEL SIZE <br /> OWNERNAME JOAtlf1 BUCK: _ADDRESS 26964 AVE. 18Y2 <br /> CrrY/7.rP LAr)ERA 93638 PHONE (559) 661-8774 <br /> CONTRACTOR NEu"1Ii�� M. DRILLIFIG CO.. FIC-ADDRESS 3 5 2 5 P E L A 110 A L E A V E. <br /> crrYi-Li i1 D ST0 CA 95356 PHONE 545-1165 _-C-s7 LICENSE#290613 EXP DATE5-31-02 <br /> GEOGRAPHICAL INFORMATION:COORDINATES X Y___TOwTISIIIP_ RANGE SECTION_ <br /> TYPF.OF WELL: ❑ NEW WELL 93 REPLACEMENT WELL ❑ MONITORING WELL.# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR O VAPOR EXTRACTION WELL 0 <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. F RST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOI.BORING X 0 D22-STRUC ION: fi 1'x appmx_ 401 <br /> INTENDED USE 'TYPE OF 1VELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DLA_12" CONDUCTOR CASING DIA <br /> )C)OOMESTTCPRIVATE XXRA\'ELPACK/S¢E_ WELL CASING TYPE PVC WELL CASING DLA 6"___.- <br /> ❑PUBLICIMUNICIPAL Cl DRIVEN GROI,TSEALDEPTH 100 SPECIFICATION bmtwite <br /> ❑IRRIGATION/AG OTHER GRovrBRAND NAME BARIOD - Quick Grout <br /> ❑MONITORING .,LJ GROUT SFAL PUMPED: b YES ❑NO <br /> II <br /> ❑CHRLSTY SOX ❑STOVE PIPE ' ', , CONCRETE PEDESTAL BY DRILLER: ❑YES f?J NO <br /> APPROXIMATE WELL DEPTH,_ <br /> PROPOSED CONSTRUCITONYDRILUNG METHOD: MUD ROTARY-_X-.ALR ROTARY AUGER—CABLE OTHER ' <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORX WILL BE DONE IN ACCORDANCE WITH SAN 1 <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS.I ALSO CERTIFY THAT MY C.57 LICENSE IS CURRENT <br /> AND ACTIVE RTT1I THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE.WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> 'l MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED �T 'b -'� _ r, E SUPERVISOR: _ DAT, 3-28-02 <br /> w NL <br /> `' I <br /> "1 <br /> 00 <br /> im <br /> I <br /> 1 � <br /> IE <br /> ias � <br /> u <br /> ux <br /> DE RTMENT USE ONLY <br /> Applicatim Accepted S t i �LDatc [ Lg ZCOLa EMPID# <br /> Ins ccted 6 Date <br /> Grout tnspectioa Bp Da1��.p p y <br /> Destruction 1mvection By <br /> COMMENTS: /�1/ A/Y�f,! �✓ f /G� —. <br /> PE Sc AMOUNT RECEIVED DATE PERMrr/SERVK'E REQUEST 0 INVOICE# WELI,B)# <br /> CODES INFO REMrrrED H BY <br /> L 3 27 n 3 1 1E <br /> q 3 5 , <br />