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WELL/PUMP PP'NIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES EN•-ONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)469-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS 7 W" L r A/ e./ APN, 1CZ/Z/2/9 y <br /> ClfyfZR' /AC 1 / PARCELSIZE .sv <br /> OWNER NAME G U&k 4 L/_.a L k ADDRESS �m <br /> CITYlZLP / J PHONE <br /> CONTRACTOR W S � <br /> CHylZIPNN �➢- PHONE C-57 LICENSE# EXP DATE <br /> GEOGRAPHICAL INFORMATION. COORDINATES X Y TOWNSHIP_ RANGE_SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: )EWELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.'P.— Z'11=— DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BOMG ❑DESTRUCTION: <br /> E➢USE TYPF.OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDO $CASI WG DIA <br /> 11 !=1V 1 <br /> )1DOMESTICPRIVATE ❑GRAVEL PACK/S1ZE WELL CASING TYPE WELti 'SQ ,,�IAI=� <br /> ❑PUBLICIMUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIPICf►TION r� <br /> ❑IRRIGATIONIAG OTHER GROUT BRAND NAME <br /> ! <br /> [3 MONITORING GROUT SEAL PUMPED: <br /> lr <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELLDEPTH <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT i HAVE PREPARED THIS APPLICATION AND TIIAT 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 /> ,,.. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS c',r` <br /> �� SIGNED ` nr s TTI1.E iG y _ DATE • 1�` <br /> h � <br /> I <br /> I <br /> � II <br /> FT <br /> IF— <br /> r <br /> 77 <br /> ➢EPA ENT USE ONLY 2 I <br /> Application Accepted By_T �� , .-- Date � — Area v `[ EMPBNF <br /> r A/ <br /> Grout Inspection By Date Pump Inspected By Dat �(/ <br /> Destmction Inspection By Date <br /> COMMENTS: <br /> PE SC AMOUNT CHECK#! RECDATE YERMIT/SERVIC <br /> EIVED EREQUEST# R4VOICE# WELL M# ' <br /> CODES INFO REMHTED CASH IIY <br /> t. <br />