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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304E.WEBER AVE,TURD FLOOR STOCKTON CA 95202 (209)468-3420 <br /> NON- ABLEFERMIT EXPIREST RMOM DATE ISSUED 17o <br /> JOB ADDRESS <br /> .1 S O` APN a 9 {l�� Z <br /> CITY/LI ARCELS6E <br /> OWNER NAME ADDRESS <br /> CITY2I PHONE <br /> CONTRACTOR VFW 'D/L I C l I N S ADDRESS P.O R-A S'/ <br /> crrY2w X10 JlsTA- 9457/ PHONE n//(i 7774(o-o C-67 LICENSEn 7.zo5b DATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES J-- Y_TOWNSHIP_ "qE_SECTION <br /> J3S,2n yS yD :f <br /> TYPEOFWELL: ❑ NEWWELL ❑ REPIACEMENTWELL YTyMONTIORINGWELLk "�•�` Y �O OTHER <br /> INSTALLATION: OWELLSYSTEMREPAIR ❑CROSS-CONNECTREPAIR OVAPOREXTRACTIONWELL0 <br /> TYPEOFFUMP: ONEW 0REPAIR H.P. DEPTH PUMP SET F>r. PItSTWATERLEVEL <br /> ❑OUT-OP-SERVICE WELL ❑OEOIECHNICALA OSORBORING ❑DESTRUCTION: <br /> INTENDED USE TYw.OF WRI I. CONSTRUCTION SPECIFICATION ' <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELLEXCAVATIONDNA FSI CONDUCTOR CASING DK-A,-/& <br /> $� 1 <br /> 13 DOMESTIC PRIVATE ❑GRAVEL PACK/SR8�•p0 WELL CABING TYPE PVG WELL CASING DIA A �L <br /> ❑PUBUCIMUNICIPAL ❑DRIVEN GROUTSEALDEPIH /1 SPEECCIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME alo � amf " <br /> {RMON IORING GROUT SEAL PUMPED: O YES ONO <br /> O CHRISTY BOX KSTOVEAAPIE SSCOTNCREIM PPEDESTAL B DRIIPR:'❑ ONO <br /> APPROXIMATE WELL DEPTH A�.-p <br /> PROPOSED CONSTRUCTIONMRRI.WG METHOD: MUD ROTARY_AIR ROTARY x AUGER CABI&_OTHER_ <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TIT+WORK WILL BE DONE IN ACCORDANCE WEILL SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS.I ALSO CERTIFI'THAT MY C37 LICENSE IS CURRENT <br /> AND ACTIVE WPPR THE CALT+ORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> MINIMU 2 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS //11 <br /> SIGNED ��- TITLE SEs✓o.� !'C-a40 <br /> e •a-� <br /> w6aR IUVn a aR l6we <br /> xoa-o]o-4 <br /> 33 34 / <br /> Aw uxzf C <br /> 308-040-] <br /> zaa-no-z 4Z <br /> W6RJER Opp6R 3�p,,o <br /> 09 p <br /> eJ„ <br /> 209-040-9 r NR a' R _ <br /> "W x2zmmmx m :w-16o-os 1 <br /> aBn 208-160-1 209-160-2 x09-no-e y-r ` <br /> SANJ <br /> m Ea <br /> IR1119NY no\ <br /> vo.-Iw-9v <br /> _ xp9-ts9-.]� <br /> Hill III ill -1 -17-1 <br /> DNT USE ONLY ""' -- 73 S'o <br /> APPIic fi.A.qp By to <br /> Groin Tospawoo By ¢ -� Axx-pvAloalpeaM Y I6TTT/��ST•oTT)� <br /> Dmtml ti..Insp.m <br /> COMMENTS: {]� —/•Uf SFII 1-� -frloN N$ <br /> BOMf1.47bb aND A2e1,AS A'r AQlm,xl. 1 (A4Al /S(H241 1-5-01 <br /> PE SC AMOUNT CHECK#/ RECEIVED DAM PERM /8 VICEREQUBSTM WVOICEM WEILmp <br /> CODES INFO HEMMED CASH BY <br /> s s� <br /> fyr3l c'6 qlo sz 3 <br />