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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)465-3420 <br /> NON-RE FUNDAB E PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS APN Q.S <br /> CITY/ZIP I—c PARCEL <br /> SIZE_7 <br /> OWNERNAME A`S (201 d a n i ADDRESS /fA CI <br /> CITY/ZIP PHONE 36 SZO 6 <br /> CONTRACTOR t"10�� r 7 U��1 ADDRESS <br /> CIIY/LLIP _PHONE C-57 LICENSE# EXP DATE <br /> I <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y TOWNSHIP_ RANGE—SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> I <br /> i <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# t <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET 1T. FIRST WATER LEVEL <br /> t <br /> I <br /> OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOI-BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELLCASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <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 /> I <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN O! <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 /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS ' <br /> SIGNED er-( TITLEDATE <br /> g� <br /> EN RD ME TAI HEA 3H IVI. <br /> 1 <br /> \ DEPARTMENT USEON1,Y � o <br /> Application Accepted By .�r Dated2 10 EMPiD#. 110 I <br /> 1 <br /> Grout Inspection By Date_ Pump Inspected By ___ __ Date - <br /> i <br /> Destruction Inspection By Date <br /> COMMENTS: <br /> PE SC AMOUNT C #/ RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL ID# <br /> CODES INFO REM CASH BY <br /> 17Y ZODi J 21r S.GGA.7�/�-z, D .538 <br />