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Ifte WELL/PUMP PERMIT— <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)4WELL <br /> 68-3420 <br /> I <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS �(7L kn6/C/'1!✓-�( /1/.Fz& APN c2..3 2 So.1 <br /> CITY/LB' n/ ( 4i JJ / / PAR L SIZE 24c ' -S <br /> OWNER NAME 1 0e CJI I/C'f'�C ADDRESS j 6 U10V �/✓ ��//����/l�tt' <br /> CITY/LI' I G 6- PHONE X34! <br /> CONTRACTOR Arl ADDRESS •D. 1191K !V42 <br /> CITY/LIP TJ PHONE O - C-57 LICENSE#. 77rn <br /> / EXP DATE_;7___012 <br /> .� GEOGRAPHICAL INFO <br /> ORRMATION: 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 WELL EXCAVATION DIA14Z_� CONDUCTOR CASING DIA_ <br /> DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE-,gL WELL CASING TYPE. WELL CASING DIA_H_ <br /> ❑PUBLICJMUNICIPAL ❑DRIVEN PAYMEN ' <br /> RECEIVE!: GROUT SEAL DEPTH_ SPECIFICATION Sq.' L� <br /> .` <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME [ O7(r Y <br /> ❑MONITORING CCT 3 1 2001 GROUT SEAL PUMPED: dy`ES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE / SAN JOAQUIN CO!JNTI'CONCRETE PEDESTAL BY DRI #c.LER: iiS ❑NO <br /> Ej & C> PUBLIC HEALH SEWCE5 <br /> APPROXIMATE WELL DEFPH ENVIRONPAFK:,'.A.,�.q-.,j-, <br /> PROPOSED CONSTRUC ON/DRIJ.ING METHOD: MUD ROTARY - AIR ROTARY AUGER CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE 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 IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> MI MUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE p/pL,pS- DATE O O <br /> Lit mm <br /> r <br /> r <br /> r <br />