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ELL/PUMP PERMIT / OFT <br /> SAN JOA 04 E.COUNTY PUBLIC HEALTH SERVICES EN CA 9520 ENTAL HEALTH DIVISION"304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 � <br /> �J �iNON-REFUND+ABLE�PE�RMIT EXPIRES 1 YEAR FROM DATE ISSUED p <br /> JOB ADDRESS g �}�[� APN._ —ZO / /9� O y2 <br /> CTTY2lP PARCEL SIZE ar-AuV/.I- <br /> OWNER NAME?-' n-t ADDRESS <br /> CITY/LIP - <br /> / PHONE <br /> CONTRACTOR/+ G/ --DR,C C-r.�� ADDRESS to, <br /> C1TY/L@_/e-!O V/S IA 94� PHONE 9 IL 7 7 7 �/O--D C-57 LICENSE# f: �,XEXP DATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES 11`_ Y— TOWNSHIP_ RANGE_ SECTION - <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL rZ�� ❑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# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIAZS I CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑URAVRL PACK/SIZE-0.016 WELL CASING TYPE - P/ C WELL CASING DIA 22 �� <br /> ❑PUBLIC/MUNICIPAL 13 DRIVEN GROUT SEAL DEFTH SPECIFICATION <br /> ❑IRRIGATION/AG - OTHER GROUT BRANDNAM <br /> kMONITORIVG GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX A�STOVE PIPE CONCRETE PEDESTAL BY DRILLER: (KYES ❑NO <br /> APPROXIMATE WELL DEPTH J. C t /N A-.{' —oiiY[ <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY_AIR ROTARY--A-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 /> COMPENSATION LAWS. <br /> INIM OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGN Nom-- TITLE DATE <br /> -' QUARTER CORNER <br /> SEE x <br /> H E" ROAD <br /> 6 209-040-9 ST UNE OF <br /> 209-040-4 � HENDERSON RD. 209-160-09 <br /> EE DETAIL "B" 209-160-1 209-160-2 a 209-310-8 <br /> 209-040-13 -� <br /> q z <br /> z <br /> rSOUJ <br /> TH LINE OFi <br /> BETHANY RD.\ <br /> --------- - <br /> ETHANY OA <br /> POINT "Co _ <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Dal.--4L-2z/ Area EMPID# <br /> Grout Inspection By Date Pump Inspected By - Date <br /> Destruction Inspectio Date <br /> COMMENTS: O <br /> v vv <br /> PESC AMOUNT CHECK#/ RECEIVED DATE PERMIT/SERVICEREQUEST# IJVOICE# WELL ID# <br /> CODES INFO REMITTED CASH BY <br /> r a °� <br />