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WELUPUMP PERMIT <br /> SAN IOAQUIN COUNTY PUBLIC HEALTH SERVICES FNVItONMENTAL HEALTH DIVISION <br /> 304E.WEBERAV$THIXD FLUOR STOCKTON G 95202 (209)x68-3420 <br /> NON-REPUNDA�E PERMITIRFS 1 YEAR FROM DATE ISSUED , <br /> FC <br /> S A= TI <br /> l t V <br /> _PARCEL S6E .17 J11Che.Fj <br /> Cot d a n i ADDRESS__L3/q q N- <br /> ^ i I / SHONE 36 5 SZO 6 <br /> CONTRACTOR A �!e 9�R�b4.� MDRFSS C,t�4 I <br /> GDY/L� nBwg <br /> GSY LICENSESN *+RPDA'1S--- <br /> GEOGRAPHICALDNFORMATION: COORDINATES K_ Y TOWNSIDP_ RANGE_.SECTION <br /> TYPEOFWELL: 17 NEWWCLL p RBPLACEMENTWELL p MONRORINGWELLY pDTIiPR <br /> HaTALLAMON: p WELL SYSTEM REPAIR EICROSSCONNECTREPAIR O VAPOR EXTRACTION WELLY i <br /> TYPEOFPUMP: ANEW 13 REPAIR HJ+. DEP PUMP SET PT. FIRST WATER LEVEL <br /> OUTOFSBRVICE WELL 13GEOTECHNIGL0 OSORBORING ❑DESTRUCTION: 'I <br /> INTENDED USE TYPE OF WILL CONSTRUCTION SPECLFI ATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELLEXCAVATIONDIA CONDUCI'ORCASMDIA_ <br /> 13 DOMESTIC PRIVATE p GRAVEL PACKIS¢E WELLCASINGTYPE WELLCMWGDLA <br /> p PUBLIC/MUNICIPAL 0DRNEN GROUTSEALDEPI3L SPECIFICATION <br /> p IRRIGATIOMAG OTHER GROUT BRAND NAM I <br /> p MONITORING GROUTSEALPUMPED: AYES ONO <br /> ❑CHRISTY BOX ❑WOVE PIPE CONCRETE PEDESTAL BY DRILLER: 13YES p NO <br /> APPIROXIMATE WELLDEPTH �I <br /> PROPOSED CONSTRUCDONIDRILLING METHOD: MUD ROTARY_AIR ROTARY_AUGER_CABLE_O'T'HER N I <br /> I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TRE WORK WILL.BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS 1 ALSO CERTIFY THAT MY C-57 LICENSE IS CURRENT <br /> AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKMAN`S (� <br /> COMPENSATION LAWS. C I <br /> •[^/ MINIMUM <br /> ,�24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS I <br /> SIGNED Y��T _I "t�C�OC., TnLE DATE <br /> i <br /> ------ ------- <br /> IHS <br /> I <br /> i <br /> RU W TPI H TH <br /> I <br /> ' DEPARTMENT USE ONLY y O <br /> Applicum AacplW By m `/At' nl Area IL' EMPBO.,-J& f_ <br /> Gc Tespevim By Pump Loxpemd BY WR <br /> D clim I pccum By <br /> COMMENTS: <br /> i <br /> PE SC AMOUNT CRECKW RECENED DATE PBRMU/SP.RVICEREQUESTO INVOHCB WELLmY <br /> CODES INFO REM CAS BY-q366 17S' 10D 4go <br /> 1I2.1, -4,f9 <br /> � I <br />