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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 JQ'�`-7"L"`1 /C 4wee'- <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1�ZS 4"/14 APN O_ 2.1 <br /> CITY/L __ Pl p° PARCEL <br /> OWNER NAME. yl� 6arf� ADDRESS <br /> CTCY/LIP PHONE <br /> CONTRACTOR K-L7fN/�I'I^^L•-2�O 6,�L ADDRESSh�/� <br /> CITY/L1P ��KnJ 7 S 7.0 PHONE G���l S'�J C-57 LICENSE#( b -EXP DATE IZ O <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 � Fr. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM ®EXCAVATION DIA�-tl , CONDUCTOR CASING DIA_ <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE_ WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME &Y.2�,Pk*Gr /r- //J rn W <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> T r <br /> APPROXIMATE�'!i .DEPTH <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY_AIR ROTARY AUGER K_CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN i <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY C-57 LICENSE IS CURRENT r <br /> AND ACTIVE WITH THE CALIFORNIA CONT CTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. 4 <br /> M OUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS p IT <br /> SIGNED TITLE <br /> Z <br /> -jl o <br /> -Q 2 <br /> 0 <br /> E % <br /> R/ver Rand 3 7o Berlin Nnrh <br /> [se6 a;om <br /> 6 C <br /> 2 I 7 <br /> Barton N <br /> Milgeo Rood ® Ranch <br /> S/�nSY W <br /> n xam, wnmam ,_t �• <br /> � n•:amn.w.,v meew K,.�t i int _ <br /> m wa <br /> T.Ml Y.+y �ea 314 f. <br /> ageu r.m,yx me 9°:,�,m ae eeM•w a aab.. <br /> rj <br /> �. WahA b qe dNm A6rA�S^m0 nM @ Yw mon d <br /> 'T'z9,y er v4 a1 1s MMl✓W m!MiW <br /> _ �Pd'.is�"n JI('M AI 1 U.�. I I{I.(I�l:• <br /> DEPARTMENT USE ONLY 7 _ <br /> Application Accepted By / Da[e G'o 3 Z Area G l� EMPID0�37 V <br /> Grout Inspection By Datei lzz mp Inspected By Date <br /> Destruction Inspection By i - Date <br /> COMMENT <br /> PE SC AMOUNT .CHEC RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL ID# <br /> CODES INFO REMITTED H BY <br /> 4371 150 230 411_ qf Lab. 4-4 _'L 59 <br />