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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 /> ON-�REFFUNDABLE PEI EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �f '/' Lo/zs <br /> CITY/ZIP D APN <br /> ,Q PARCEL SIZE <br /> OWNER NAME `' )) *���VW ADDRESS <br /> CITY/ZIP L r� l C%L � <br /> PHONE <br /> CONTRACTOR � <br /> ADDRESS <br /> CITY/ZIP PHONE <br /> C-57 LICENSE# EXP DATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: Cl NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# <br /> ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR Cl CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET <br /> Irl'. FIRST WATER VEL <br /> KOUT-OF-SERVICE WELL 13 GEOTECHNICAL# ❑SOIL BORING <br /> ❑DESTRUCTION: <br /> E E TYPE QF � <br /> E <br /> . CONSTRUCTION SPECIFICATIOrT <br /> 11 INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACKISIZE WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH <br /> SPECIFICATION <br /> RIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> D CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: 17 YES ❑NO <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CER THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN CO RDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY C-57 LICENSE IS CURRENT <br /> AND ACTIVE THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> �F I M 4 HO <br /> 0 ADVANCE NOTICE REQUIRED FOR INSPECTIONS � f <br /> SIGN �— _ `J f1 <br /> } <br /> 1 V <br /> I <br /> ATM <br /> v <br /> A <br /> 1 W21� <br /> W" 0 d as <br /> �> r <br /> d, <br /> �z hi W <br /> W _ <br /> C w <br /> q <br /> (\� • e <br /> J I. <br /> a u `V <br /> FJ �u W-4 <br /> 55'1 ,l1 0a9 <br /> DEPARTMENT USE ONL <br /> Date - OI '". <br /> Application-Accepted By.= Air agr 2, D# <br /> Grout Inspection By Date Pump Inspected By Date j <br /> Destruction Inspection By Date <br /> COMMENTS: <br /> I <br /> PE SC AMOUNT CHECK#/ RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL ID# <br /> CODES INFO REMITTED CASH B <br />