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ELUPUMP PERMIT <br /> SAN 70AQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 '..i ISI JI✓�J M <br /> NON-REFUNDABLE <br /> QPERMIT EXPIRES 1 YEAR FROM DATE ISSUED / <br /> JOB ADDRESS I / -3 APN EZ0 9 Iry vC <br /> C177Y2B' PARCEL SIZE t �" <br /> OWNER NAME—t tit ADDRESS <br /> CITY/ZIP PHONE <br /> CONTRACTOR V+ -ADDRESS O Y S' / <br /> C1TY/Zp Q i O V es—A IF-,/,i;-7/ PHONE / lL 7 7 7 4I/&-D C-57 LICENSE#7-2 o EXP DATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES Y__ Y TOWNSHIP_ RANGE_ SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL �' MONITORING WELL# .�SI ,7.1 to ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL#' <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICEWELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WEL CONSTRUCTION SPECIFICAT16N ,A <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA J-S I CONDUCTOR CASING DIA A 2 r <br /> S�J�a <br /> ❑DOMESTIC PRIVATE ❑GAhV&L PACK/SIZE O.-O WELL CASING TYPE - P C WELL CASING DIA <br /> ❑PUBLICIMUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRANDNAM -�o,�� Tu SuL�r1cC <br /> MONITORING - _ GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX STOVE PIPE- CONCRETE PEDESTAL BY DRILLER: D);YES ❑NO <br /> APPROXIMATE WELL DEPTH -.a <- r M A-,r <br /> PROPOSED CONSTRUCTION/DRILLING 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 /> /ol -COMPENSATION LAWS. <br /> INIM OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGN -- ATF-1h141 <br /> —' QUARTER CORNER <br /> SEE x <br /> 01 E 11 ROAD <br /> 6 209-040-9 T LINE Of ° 209-160-09 <br /> 209-040-4Ol HENDERSON RD. <br /> EE DETAIL "B11 209-160-1 209-160-2 a 209-310-8 <br /> 209-040-13 -� _ <br /> ry 1N UNE of <br /> BETHANY RD <br /> \ <br /> 209-150-29� <br /> 8 ETHANY OA <br /> POINT "C' <br /> i_ <br /> DEPARTMENT USE ONLY <br /> Application Accepted By -Date1 Area - EMPID#_ <br /> Grout Inspection 13 Date Pump Inspected By - Date <br /> Destruction Inspectio o Date <br /> fL <br /> COMMENTS: ,Q <br /> PE SC AMOUNT CHECK#/ RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE#. WELL ID# <br /> CODES INFO REMITTED CASH BY _ <br /> J r1lJ <br />