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WELLTUMP PERMIT �n SANIOAQUTA UNTYPUBLIC HEALTH SERVICESENVIRONMENTAL HEALTH DIVI ON x 304 E.WEBER AVE,THIRD F=R STOCMN CA 95262 (209)468 3420 t S NON REFUNDABLE PERAUT EXPIRES I YEAR FROM DA . JOB ADDRESS t'j � CITYILIP, LL x 1 1 Pl rY� ` I PARC OWNER NAyME y - I(Ije 15DDRESS PHON CONTRACTOR DRESS9.n- P—Y1Y ff:Aq CITYlZ[P r PH I - C 57 LICENSE#-a 1 1 2iLEXP DATE I t?3 GEOGRAPHICAL INFORMATION COORDINATES X X TOWNSIIIP_ RANGE—SECTION TYPE OF WELL ❑ NEW WELL, ❑ REPLACEMENT WELL ❑ MONITORING WELL# QZOTHER INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# TYPE OF PUMP ❑ NEW ❑REPAIR H P DEPTH PUMP SET FC FIRST WATER LEVEL ❑OUT OF SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING {DESTRUCTION 0F au bI,L 4)C l f INTENDED USE TYPE OF WELL ❑INDUSTRIAL ❑OPEN BOTL'OM WELL EXCAVATION DIA CONDUCTOR CASING D1A ❑DOMESTIC PRIVATE AGRAVEL PACK/SIZE WELL CASING TYPEPyC WELL CASING t�^ ❑PUBUC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPM SPECIFICATION �pp C]IRRIGATIONlAG OTHER GROUT RAND NAME--W S;1 CIM.-s.t Rn� ytnC. bla4kc CvEry IDP�G}^ WL4h ProJce-+,I vS t4a pe,4 a+ L7 MONITORING GROUT SEAL PUMPED ❑YES ❑NO ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER ❑YES ❑NO APPROXIMATE WELL DEPI7i PROPOSED CONSTRUC71ON/DRIILING METHOD MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS I ALSO CERTIFY THAT MY C 57 LICENSE IS CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S COMPENSATION LAWS G 41Ni M 24 H R ADVANCE NOTICE REQUIRED FOR INSPECTiONq SIGNED I'7 9 zitt a i DEPARTMENT USE ONLY Application Accep DaW Grout Inspection By Date Pump Inspected By Date Destruction Inspection By ate COMMENTS Our aP J f0 F3 • PE Sc AMOUNT CHET RECEIVED DATE PERmmsERVICEREQUEST* INVOICe# WELL ID# CODES INFO REMITTED CASH BY ':Up 2.7