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1IIIIIIIIII <br /> WELL/PUMP PERMIT Copy <br /> SAN IO.304 COUNTY PUBLIC HEALTH SERVICES ENCA95202 NT(20 HEALTH 0 304 E.WEBER AVE,THIRD,FLOOR STOCKTON CA 95202 (209)466 3420NON•REFUNDAIILE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> 7ADDRESSS _ APN_ �-� 9 o�/O 'J <br /> CITY2ff - PPARCEL SIZE_ Qom_ <br /> OWNER NAME'�rm -� •ADDRESS <br /> CITY/LIP ,q PHONE <br /> CONTRACTOR... y-L✓ •� K t �S ADDRESS P O `3 O Y' <br /> PHONE 91 G 797 �//Oo G57 LICENSE#7:?a 90 EXP DATE <br /> GEOGRAPHICAL INFORA,IATION: COORDINATES X__ tY_ TOWNSHIP_ RANGE_ SECTION <br /> .... IS, / it <br /> TYPE OF WELL; ❑ NEWWELL '- p - REPLACEMENT WELL MONITORING WELL# POTHER <br /> INSTALLATION; ❑WELL SYSTEM REPAIRO CROSS-CONNECT REPAIR -. ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.A. DEPTH PUMP SET FT. FAST WATER LEVEL <br /> ❑OUT-OF-SERy10E WELL p GEOTECHNICAL# p SOIL BORING - ❑DESTRUCTION: <br /> INTENDED USE -TYPE OF WELL - :CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL{ p OPEN BOTTOM WELL EXCAVATION DIA <br /> S CONDUCTOR CASING DIA N4 <br /> pDOMESTIC PRIVATE .. ❑GRVA6LPACK/SIZE O,0/0 WELL CASINO TYPE . P�G WELL CASING DIA _�I- <br /> ❑PUBLIGMUNICIPAL p DRIVEN GROUTSEALDEPTH SPECBICATION <br /> ❑IRRIGATION/AO OTHER GROUT BRAND NATvIE 1. �o�Ui ,SV E,:XC. E <br /> AMONITORIVO _ GROUTSEALPUMPEP: ' ❑YES ONO <br /> ❑CHRISTY BqX WTOVE PIPE - CONCRETE PEDESTAL BY DRILLER: RYES ❑NO <br /> APPROXIMATj WELL DEPTH <br /> PROPOSED,COISTRUCTION/DRB.LMG METHOD: MUD ROTARY_AIR ROTARY '—AUGER CABLE_ OTHER <br /> I HEREBY CERTIFY THAT I.HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL HE 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 TILE CALIFORNIA CONTRACTORS STATELICENSEBOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> • - - COMPENSATIONS LAWS. - <br /> MINIMU 4 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE SE.✓�a/t. �C-x al it 'T <br /> DATE O <br /> 14 <br /> SEE <br /> If Elt ROAD <br /> 9 209-040-9 b4l <br /> 'WEST LINE OF ° <br /> 209-040-4 pN HENDERSON RD. <br /> EE DETAIL ' "B° 20,8-160-1 <br /> 209-160-2 00 <br /> 209-040-1'3 <br /> z ' <br /> Tti LINE DFi <br /> BETHANY RD\ - ' <br /> 209-150 29 <br /> 'PQ 209-150-30 <br /> I 9 I 0 �ETNANY JOA <br /> EPARTMENT USE ONLY <br /> Application Accepted By Date - Arca EMPID# <br /> Grout Inspection By - Datc Pump Inspected By - - Date <br /> Destruction ins <br /> pec' Hy - Date <br /> COMMENTS: 'c4lm/ <br /> Vr IV <br /> PE SC AMOUNT 'CHECK#/ RECEIVED DATE ...PERMIT/SERVICE REQ INVOICE# WELL 11)# - <br /> CODES 1NF0 REMITTED. CASH BY <br />