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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)468-3420 - <br /> \ -fie NON-R$ ABLE/PERMIT EXPIRES I�IYYEEAR FROM DATE ISSUED q /17o <br /> JOB ADDRESS I X r 1^Q V ;"Vh/1/� Ieu F-�' r' APN ?a / Tb6^ Z <br /> CTI'1'IZIPPARCEL SIZE <br /> OWNER NAME 'N ADDRESS <br /> C rYlL1P - PHONE <br /> CONTRACTOR ✓fW -bQ I L t-1 N S ADDRESS P.D S <br /> C17y/ylp 410 ylNS Tf}' 9 4 S 7/ PHONE 'T/{ 7 7 7 4//trb C-57 LICENSE# XP DATE- <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y TOWNSHIP_ RANGE SECTION <br /> �y <br /> , 3S,3n 4s Y� S <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL I{A MONITORING WELL# �'�,.-a-i?-m �❑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-SERVICE WELL ❑GEOTECHNICAL# - ❑SOI.BORING - ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION- '' ''. <br /> ❑INDUSTRIAL 13 OPEN BOTTOM WELL EXCAVATION DIA A S r CONDUCTOR CASING DIAL <br /> ❑DOMESTIC PRIVATE ❑GRAYE16.PACK/SIZE •of O WELL CASING TYPE PV C= WELL CASING DIA A r <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATIONAA <br /> ❑IRRIGATION/AG - OTHER GROUT BRAND NAME ryf.Iti.�LT± <br /> (MONITORING GROUT SEAL PUMPED: 11YES ❑NO <br /> ACHRISTY BOX O(ST)OVE PIPE <br /> PPROXIMATE WELL DEPTH o1�n iC S _CONCRETE x yd � 13 NO <br /> PROPOSED CONSTRUCTION/DRILLING METHOD:.MUD ROTARY_AIR ROTARY /� AUGER (Z/_CABLE._ OTHER <br /> [.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. <br /> MINIMU 24 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED �— TITLE Scr5,✓i0`5 r CIL 012 S% DATE_ <br /> .,r11IONG E ouuATE-� y <br /> RI WATER YAAK OF l%D RIVLR <br /> 209-030-4. <br /> 33 34 / <br /> RAVER LINE) <br /> .209-040-3 <br /> 209-170-2 <br /> QUARTER CORNER <br /> D W�(� <br /> ROAD <br /> 6 209-040-9 T UNE OF` <br /> IJt, HENDERSON RD. 209-160-09 <br /> u <br /> 18 - 209-160-1 209-150-2 g q 209-310-6 - <br /> rSO(j1N lR1E [F <br /> BETHANY R!2.\ <br /> ZANY 1Y <br /> 209-150-30 <br /> - Fra4uv n <br /> D P LENT USE ONLY <br /> 1� <br /> Application Accepted By VDate Area EMPD# <br /> Grout Inspection By Date Pump Inspected y Date <br /> Desnuction InspeClix By <br /> Date <br /> COMMENTS: ' 6141Z41J & <br /> PE SC AMOUNT CHECK#/ RECEIVED DATE PERMIT/SERVICE-REQ ST# INVOICE# WELL ID# <br /> CODES INFO .REMITTED CASH BY <br />