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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 /> ` .gyp NON-R$ ABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED c� <br /> 10B ADDRESS_T .1^O V ,S, y�r�jLi1 y(r, APN t a / <br /> 'n <br /> CTTYlZ� I l PARCEL SIZE 2�� <br /> 7,y1 f� <br /> OWNER NAMBI( z III Q.P 1\ /d�J'N"ri` ADDRESS <br /> CTf7/ZIP <br /> PHONE <br /> CONTRACTOR IV/./-el) 'D/L I C L I d !j--ADDRESS R O, R <br /> CITYILB'_�I O �//S i 9 t/S 7/ PHONE J/G 7 7 7 Z//-Cro <br /> C-57 LICENSE#�-Z o5'o EXP DATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y_ TOWNSHIP_ RA Nt� ; <br /> GE SECTION <br /> ,3n 4S YD _s- <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL Ok MONITORING WELL SS <br /> #I - _gyp 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 USF TYPE OF WELL CQNSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA S r CONDUCTOR CASING DIA <br /> gA w� <br /> ❑DOMESTIC PRIVATE ❑URAYEL.PACK/SIZE O.G 0 WELL CASING TYPE—!p V G WELL CASING DIA .2 r r <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH _ SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME ane �- <br /> KMONITORING <br /> GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX KSTOVE��IPIPE CONCRETE PEDESTAL B� DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPTH o(S 19LG�C �y(��L /2r.J..e, czdA <br /> PROPOSED CONSTRUCTION/DRI-LING METHOD:. MUD ROTARY_AIR ROTARY AUGER <br /> —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 /> COMPENSATION LAWS. <br /> MINIMU2 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED-,.-- TITLE SC-y✓ip,[ e- C-at pr/S% DATE /2� <br /> 1 <br /> 0 E OKIMAA <br /> MIWATER MARK OF OLD PoKR <br /> I <br /> 209-030-4 I� <br /> 33 34 / <br /> aAVFa uNE� <br /> .209-040-3 4 3 30'+/ /y CR. <br /> 209-170-2 <br /> QUARTER CORNER 3 <br /> ROAD <br /> 6 209-040-9 T UNE OF' <br /> HENDERSON R0, 209-160-09 - <br /> 209-160-1 209-160-2 g <br /> 209-JIO-B <br /> nlLINE YRcF <br /> BETHANY RO\ <br /> t0Y 9_159 <br /> 50 <br /> zo9-150-30 <br /> F 4ANY O <br /> D PIENT USE ONLY <br /> Applicatioo Accepted By �' Dale�Area EMPIDN <br /> T �T- <br /> Grout Inspection By Date Pump Inspected y Date <br /> Destruction Inspect: By Date <br /> COMMENTS: t,p. <br /> PE SC AMOUNT CHECK#/ RECEIVED DATE PERMIT/SERVICE REQUEST# IJVOICE# WELL ID# <br /> CODES INFO REMITTED CASH BY <br />