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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-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS OA O <br />AVE APN_—7033 <br />. rr <br />CITYPLIP <br />PARCEL SIZE <br />T <br />OWNER NAME ADDRESSr- �a�7 <br />CITY/LiP , <br />PHONE <br />CONTRACTOR_ 402M ADDR, ESS -e2 <br />��/��`� r <br />PHONE /_SjzC-57 LICENSE# f� EXP DATE <br />GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br />PE <br />CODES <br />TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ElMONITORING WELL # ❑ OTHER <br />AMOUNT <br />REMITTED <br />INSTALLATION: ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR (3 VAPOR EXTRACTION WELL # <br />RECEIVED <br />By <br />TYPE OF PUMP: ❑ NEW ❑ REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br />INVOICE <br />❑ OUT -OF -SERVICE WELL ❑ GEOTECHNICAL# ❑ SOIL BORING �ESIv <br />INTENSE TYPE OF WELT, _CQN$TRUCTION SPECIFICATION /F <br />// <br />❑ INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CON UCTOR CCpkSING DIA <br />❑ DOMESTIC PRIVATE <br />❑ GRAVEL PACK/S1ZErx <br />WELL CASING TYPE WELLCIN�G DIq��� <br />❑ PUBLIC/MUNICIPAL [3 DRIVEN GROUT SEAL DEPTH SPECIFICATION - <br />i <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 <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />I HEREBY CERTIFY THAT IMAVE 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 INCOMPLIANCE WITH ALL WORKMAN'S <br />COMPENSATION LAWS. <br />24 14OAUR ADVANCE: NOTICE REQUIR +D FOR INSPECTIONS <br />SIGNED TIME DATE <br />V7 <br />b <br />I <br />'Application Acccplcd Bye\ 1 (W%Y _' <br />Grout Inspection By <br />Destruction Inspcclian By <br />COMMBiN�T5:_ pt) c <br />4 <br />.NT USE ONLY <br />Date 13 Arca EMPID# <br />C Pump Inspected Hy <br />Wif� fiW <br />fel <br />PE <br />CODES <br />SC <br />INFO <br />AMOUNT <br />REMITTED <br />#/ <br />RECEIVED <br />By <br />DATE PERMITISERVICE REQUEST # <br />INVOICE <br />WELL IDM <br />�?0 0 S3 - <br />i <br />fel <br />