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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 95202 (209)458-3420 C , <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUEDLJOB ADDRESS-"Ye' Ade Zd S AV, `DST h J 3,d APN <br /> CITYrUP 'I'!0 fS 4 /1 JPARCEL SIZE <br /> OWNER NAME CG//1�Ah f' ADDRESS 5too Fe'/r,,,, /,>>/vql <br /> C <br /> CITYCZIP J 4 c r o—Py f o C,� /S.F-I� PHONE 910 <br /> 2-72- <br /> CONTRACTOR C� l 40 SCs p ADDRESS �d d <br /> CITYIZ� �kCK uNr Pn�o ! ���/ PHONEe11 2-2-2 ' 7 C-57 LICENSE#$ye EXP DATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP L RANGE 6 SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# 0 OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL#. <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET r . " 1. W�TA❑OUT-OF-SERVICE WELL GEOTECHNICAL# 13SOIL BORING ' ❑DN: <br /> INTENDED USE TYPE OF WELL CONS ,i�0�1, 1�!BCNVA'I'gp1red WIthoUt <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELT�I' �1� �Agg&pmp1eteC CDUCI 'OR CASING DIA <br /> : mE,--tal Health Div, n <br /> ❑DOMESTIC PRIVATE .[3 GRAVEL PACK/SIZE WELL C:��f SING WI WELL CASING DIA <br /> ❑PUBLICIMUNICIPAL, ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION t <br /> 0 IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: 0 YES ❑NO Q t <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <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-57 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. j <br /> INIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE" it C!/r '< ea, DATE / 1 <br /> elcome,Guest User 1 <br /> Create My Locations-Sfg <br /> Yahoo!Maps, , <br /> >., <br /> *Tracy,CA <br /> Save,This Add <br /> YAxool', t\, <br /> pricing pins Vlj <br /> •To 1hrS location <br /> From this location <br /> r% <br /> zoom in Map New Location ' <br /> -My f ocarlans- + Slee 1, <br /> 3 1 Addres..m4n.tlknn alpotcgae I !^ 1 <br /> * � [ 51 � <br /> [ 5 1 <br /> [ s ) Tracy,CA <br /> united states <br /> 181 <br /> 1 9 1 r•Get Map SAA <br /> f )io,) r P Cl r ti <br /> Zoom Out ®AtId AAYpe,10 My YAhool ` 'J �iA 1i •.r 1 _r � r 'f� <br /> 1 l <br /> _ 1 Printable Find Nearby services rH 1! r <br /> g 150 m <br /> snort Nearhy Businesses <br /> Email Map •ca,R.eiai5 <br /> dd P}2tg2 Taheel tie 192002 GOT b% <br /> 3' `, Gea StaNees <br /> •Holeh sed Malate <br /> Business Locator-cick on business name to view the IGcadons on map Rea a Guide Store Fmm Iraeronte` City Guide 'I <br /> �Eleven® <br /> Yahnol Tra el <br /> Application Accepted By r �� DateZ (o EMPID# �L ' <br /> Grout Inspection By Date a 27 !® Pump Inspected By Date <br /> Destruction Inspection By Date <br /> COMMENTS: <br /> I <br /> PE SC AMOUNT RECEIVED DATE PER MITISER ICE REQUEST# INVOICE# WELL ID# <br /> CODES INFO REMITTED CASH BY <br /> 472. 150 23v°' L 5 `� a7�a 'jP00Z�-2 . <br /> I <br />