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i <br /> 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 /> NON-REFUND LE PERMIT EXPIRESI YEAR FROM DATE ISSUED <br /> JOB ADDRESS 326,3 C 4/ APN `-'/ �• <br /> CITyrt lP k S�OC_ LOO N [ / -PARCEL SIZE/ <br /> OWNER NAME <br /> J Abe- f ll-rkl CAADDDRFSS ,d��f �/� 4 /1�� <br /> CITYrLIP /�G 1 s [ CSC.A PHONE— <br /> CONTRACTOR— ADDRESS <br /> CITY/LIP PHONE C-57 LICENSE# E"DATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP_ RANGE_SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL* <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FTRSr WATER LEVEL <br /> )(OUT-0F-SERVICE WELL ❑GP.OTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WFC CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELLCASING DIA <br /> ❑PUBLICIMUNICJPAL ❑DRIVEN GROUT SEAL DE1117H SPECIFICATION <br /> ❑IRRKIATIONlAG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> \ <br /> APPROXIMATE WELLDEP7H 120 _ 1_ <br /> PROPOSED CONSTRUCTIOMDRIILTNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER Vt <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN (� <br /> JOAQUIN COU INANCES, LAWS,AND RULES AND REGULATIONS I ALSO CERTIFY THAT MY C-57 LICENSE IS CURRENT t` <br /> AND ACI ITH CALEFO TACO RACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. C, <br /> MI IMUM 'HO VANCE NOTICE REQUIRED FOR INSPECTIONS <br /> S D _ TrrLE DATE IO /0 <br /> oll <br /> i <br /> i <br /> N d <br /> Ai n <br /> �- <br /> DEPARTMENT USE ONLY <br /> Applie2 ion Accepted By' Date Area 9. Ji EM PID# <br /> Grout Inspection By Date Pump Inspecued By t�`L1r^P-y ��. male <br /> D"truction Inspection B mte <br /> COMMwFS: HR earP )I !J 0013-72 Kqn <br /> �ll0 k� 5e,.► 8-� <br /> PE SC AMOUNT 'CHECKW RECEIVED DATE P TI'/SERVICEREQU # INVOICE# I WELL ID# <br /> CODES INFO REMITTED CASH BY <br /> { N K / r- lad -le"/_ 130 a r <br /> 1 � <br />