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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DNI <br /> 304 E.WEBER AVE,THRID FLOOR STOCKTON CA 95202 (269),468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1.YEAR FROM DATE ISSUED <br /> JOB ADDRESS APN 9 d yQ <br /> CTTY/ZIP PARCEL SIZE OpLPiy <br /> OWNER NAME:---.72-,,' A1zk ADDRESS /�C GSGI.y,. �✓ <br /> CITY(LIP / PHONE <br /> CONTRACTOR':V t w ADDRESS-- f.o, 3O Y S / <br /> CITY/ZIP R/2i ✓IS'TA 9 yS7 / � PHONE 9/G 7'7 7 4/0? C-57 LIC ENSE#Z�? EXP DATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES )C Y_ TOWNSHIP_ RANGE._ SECTION . i <br /> IS, / <br /> TYPE OF WELL: ❑ NEW WELL 0 REPLACEMENT WELL ar MONITDRING WELL ❑OTHER <br /> INSTALLATION:. ❑WELL SYSTEM REPAIR OCROSS-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# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA .-_X CONDUCTOR CASING DIA A/ <br /> O DOMESTIC PRIVATE ❑GRRA�YBLPACK/SIZE 42.0/0 WELL CASING TYPE . P✓G WELL CASING DIA 3- � <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEALDEPTH 4'd 'S SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUTBRANDN <br /> 3XM0NITORING GROUT SEAL PUMPED: ❑YES ONO <br /> ❑CHRISTY BOX WTOVE PIPE CONCRETE PEDESTAL BY DRILLER: BYES ❑NO <br /> APPROXIMATE" WELL DEPTH -e2-.S I/^"/�X <br /> PROPOSED CONSTRUCTIONlDRB-LI NG 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 LICENSEISCURRENT <br /> AND ACTIVE:WITH THE CALIFORNIA CONTRACTORS SPATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> MINIMW 4 UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED - -(TITLE S19.IeC..2 -�.EcL al i.l `T DATE <br /> SEE <br /> It is _ ROAD <br /> 6 209-040-9 ! T UNE OF " <br /> 209-040-4HENDERSON RD. <br /> EE DETAIL "B" 209-160-1 209-160-2 s <br /> 209-040-13 i. <br /> J <br /> TF1 UNE OF <br /> EIETHANY RD\ F <br /> 209-150-29 <br /> 209-150-JO <br /> �ETIANY OA <br /> - - EPARTMENT USE ONLY <br /> IL <br /> Application Accepted By DatetAreaEMPID- <br /> # . <br /> Grout Inspection By Date Pump Inspected By Date <br /> Destruction lnspec' By Date <br /> COMMENTS:./��i0?�' 1 <br /> PE SSC AMOUNT CHECK#/ RECEIVED _.DATE PERM MSERVICE REQUEST# INVOICE# WELL LD# <br /> CODES INFO REMITTED CASH- BY <br />