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WELL/PUW PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE,THIRD PIAOR STOCKTON CA 95202 (209)468-342D <br /> NON- ABLE PERMIT E KITRF.S 1 T R FROM DATE ISSUED <br /> !OB ADDRESS , O Z <br /> CITY2,IP <br /> OWNER NAM pS �•b I•. � . <br /> C1TYfZIP <br /> ONS_ <br /> CONTRACTOR w rL I L 1.1 N DRrss P.o A <br /> Crrrao• 1Q r n, ± cy 41 r 7 PHONE 5Y�_7�7 4lao <br /> C-57 LiCENSBp`7,� /a''b ➢ATB <br /> GROGRAPMCAL INFORMATION; COORDINATES X Y—TOWNSEW G8_SECTION <br /> TYPE OF WELL: p NEW WELL 12 REPLACEMENT WELL OK sr3A 4 WDA S <br /> Wy MONITORING WELL N `p O7}IF,R <br /> INSTALLATION: CI WELL SYSTEM REPAIR O CROSSCONNECT REPAIR O VAPOR EXTRACTION WELL N <br /> TYPE OF PUMP: 0 NEW I3REPAIR H.P. - DEPTH PUMP SET .,,Nt', FIRSTWATERLEVEL <br /> 0 OUT-0F-SERVICE WELL O GE9MCHNICAL413 SOIL BORING []DESTRUCTION: <br /> m3mmDuSy. T]PE OF WELL CONSTRUCTION SELaBC&U= <br /> O INDUSTRIAL 0 OPEN HOTLIOM WEILEXGVATION DW-a,5! CONDUCTOR CASING IDK-A/& <br /> O DOMESTIC PRIVATEDGR+MrVE6 PACK/SQ8�.qi 0 WELL CASINO TYPE_Ay�_ WELy GSIVO DIA,rti •r <br /> D PUBLICIMUNICIPAL O DRIVEN GROUTSEAL DEPTH SPECIFICATION <br /> D ItRIGA710N1AG OTHER GROUT BRAND N 4 � <br /> IKMONITORING GROUT SEAL PUMPED; OYES []NO <br /> ❑PROXI YBOR IQISTUVEnPIPE �� p$Tp(�gT [3 NO <br /> APPROXIMATE WELL D aS f <br /> PROPOSED CONSMUC770NIDRIIING METHOD:MUD ROTARY—ALR ROTARY_ AUGER CABLE OTHER <br /> I HEREBY CERTIFY <br /> THATIHAVE PREPA <br /> RED THIS APPLICATION ANDTHAT THE WORK WILL BE DONE 1N ACCORDANCE W17T1 SAN <br /> JN QUINACTTWCOUNTY ORDINANCES,ECALIFORNIASPATE LAWS AND RULES AND REGULATIONS I ALSO CERTIFY THAT MY C-57 LICENSE IS CURRENT <br /> AND ACTIVE WITH THE CALD+ORCONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE Wrm ALL WOPJUAA" <br /> COMPENSATION LA WS <br /> MINIMU 2 OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> r SIGNED � ool <br /> — <br /> ✓� a or, S r DA <br /> AT AWM'09 <br /> a <br /> WAR*KW Of RY 101st <br /> r <br /> 209-030-4 x <br /> 33 34 !/ <br /> AVER <br /> .209-040-3 4 W+ v - <br /> 209-170--2 <br /> WARIER CORM - <br /> 3��4�0 <br /> AD <br /> d' 209-040-9 T t9M OF <br /> IEtt0M=M. 209-160-09 <br /> ,gam <br /> 209-Ie0-1 209-160-2 <br /> � 209-I10-e <br /> reETttARr tb.� <br /> 22-179-7- J <br /> E <br /> 209-159-3R <br /> D P USE ONLY — - <br /> Applicatio9 Accepted By ® ETED <br /> k to PB]II <br /> Grout Iespced 11 AI ted y /-,�-•o) <br /> DesOucdon Ems <br /> � u <br /> t- <br /> COMMENTS- <br /> 'WFC 3'AT 1.�rf77oRJ ' <br /> -OI e <br /> PE SC AMOUNT CHECKLN RECEIVED DATE PERM r VICE REQUFS7ii INVOICE M WELL m11 <br /> CODES INFO REMITED CASH BY <br />