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#2154 <br />ALTH DIVISION <br />10100 Lower Sacramento Road APNJOB ADDRESS. <br />95210Stockton PARCEL SIZE.CITY/ZIP. <br />433 N. Sierra Nevada StreetVai San Associates ADDRESS.OWNER NAME. <br />948-618195295StocktonPHONE.CITY/ZIP <br />646 S. California St.Delta Stockton Pump ADDRESS.CONTRACTOR. <br />O466-962595203Stockton EXP DATE.C-57 LICENSE# PHONE.CITY/ZIP. <br />RANGE SECTION TOWNSHIP.GEOGRAPHICAL INFORMATION: COORDINATES X.Y <br /> OTHER MONITORING WELL #.REPLACEMENT WELLTYPE OF WELL:NEW WELL <br /> VAPOR EXTRACTION WELL#. CROSS-CONNECT REPAIR WELL SYSTEM REPAIRINSTALLATION: <br />86'147'IkXXrepair FIRST WATER LEVELFT.DEPTH PUMP SET NEW HP,TYPE OF PUMP:F~ <br /> DESTRUCTION:. SOIL BORING GEOTECHNICAL#. OUT-OF-SERVICE WELL <br />CONSTRUCTION SPECIFICATIONTYPE OF WELLINTENDED USE <br />CONDUCTOR CASING DIA.WELL EXCAVATION DIA. OPEN BOTTOM INDUSTRIAL <br />WELL CASING DIA.WELL CASING TYPE. GRAVEL PACK/SIZE. DOMESTIC PRIVATE <br />SPECIFICATION.GROUT SEAL DEPTH El PUBLIC/MUNICIPAL DRIVEN <br />OTHER GROUT BRAND NAME. IRR1GAT1ON/AG <br /> YES NOGROUT SEAL PUMPED: MONITORING & <br /> NO YESCONCRETE PEDESTAL BY DRILLER: STOVE PIPE CHRISTY BOX <br />275'APPROXIMATE WELL DEPTH. <br />OTHER CABLEAUGER AIR ROTARY PROPOSED CONSTRUCT1ON/DRILLING METHOD: MUD ROTARY. <br />10/15/02DATE.TITLE.SIGNED. <br />pm 7 <br />3 <br />l 1EKL TV7TT <br />EMPID#.Area.Date.Application Accepted By. <br />Date.Pump Inspected By.Date.Grout Inspection By. <br />Date.Destruction Inspection By. <br />COMMENTS: <br />WELL ID#INVOICE #PERMIT/SERVICE REQUEST # CHECK#/DATE <br />051 ~T5 1 <br />“• ■* s 11 <br />MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />CEO <br />1^-03 <br />PE <br />CODES <br />43S0 <br />sc <br />INFO <br />AMOUNT <br />REMITTED <br />SAN JOAQUIN Ct <br />304 E. WEBER AVE, THIRD FLOOR STOCKTON CA 95202 <br />O o <br />WELL/PUMP PERMIT <br /><FY PUBLIC HEALTH SERVICES ENVIRONMENTAL <br />(209) 468-3420 <br />A <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />0^4--020-01 <br />£ <br />DEPARTMENT USE ONLY <br />II-1T- -0^ <br />0'4 d?__ <br />^4^ <br />a. <br />tj <br />RECEIVED <br />BY <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-S7 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 />c! c