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WELUPUMP 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 /> NON•REFUND�BLE PERMIT EXPIIRRES/I YEAR FROM DATE ISSUED <br /> JOB ADDRESS AMER I <br /> 2(o C 1 Nrv�PP /�/t APN `-'� <br /> V w'—s-cam <br /> CITYrcJP SL`U'G L O N / AJ$CEL SIZE a�K u <br /> OWNER NAME S f l-lLrk 1tll CMDDRESS lIy/ <br /> CITY/LIP A f - PHONE <br /> CONTRACTOR` ADDRESS <br /> CITY/LIP PHONE _C-57 LICENSE# EXP DATE <br /> GEOGRAPMCALINFORMATION: COORDINATES X Y TOWNSKIP_ RANGE_SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELLJE ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR O CROSS-CONNECT REPAIR ❑VAPOR EXTPAC71ON WELL* <br /> TYPE OF PUMP ❑ NEW ❑REPAIR H.P. DEPTH PUMP SETPT- FIRST WATER LEVEL <br /> )(OUT-OF-SERVICE WELL ❑OEOTECHNICAL# ❑SOI.BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF VMI,, CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WEILCASINGDLA <br /> ❑PUBLICIMUNICIPAL ❑DRIVEN GROUT SEAL DE111 1 SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPTH 120 <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER �L <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND 719AT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN (� <br /> ]OAQUIN COU INANCFS, LAWS,AND RULES AND REGULATIONS I ALSO CERTIFY THAT MY C-57 LICENSE IS CURRENT t` <br /> AND ACT TTS CALEFO CO CTORS STATE LI•'ENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN S <br /> COMPENSATION LAWS. C, <br /> MI ,IMUM lHo VANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SI NED _ TrrLF DATE ZO /�_ <br /> _ f <br /> ol <br /> I <br /> i <br /> I <br /> h <br /> DEPARTMENT USE ONLY <br /> Application Accepted By' —Date Ara__.9-Ili EMPIDII <br /> i <br /> Grout Inspection BY _Date Pump Inspected BY <br /> Destruction Inspection By /� •7 to <br /> COMMENTS- NR ��`1t P — �2��1)/S' 1�� ,�7 S (y�ioK rn <br /> �P ll ��.1 1 nT'1L� �i �JUII- cY•�.. }Pi••t1vcL _ <br /> PE Sc AMOUNT HECK RECEIVED DATEP 1T/SERVICEREQU # INVOICE# WEiLID# <br /> CODES INFO REMrMD CASH BY <br /> q3i,q 1 r ZOD0D TO, a/ 5,e :7Z0,13 <br />