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I <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVBIONMENTALHEALT'H DIVISION <br /> 304 E.WEBER AVE.THIRD FLOOR STOCKTON CA 95202 (209)468-3420 f <br /> NON-REFUNDARLF,PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS jai/ ` I�G K rJ APN Q-�I- /Z9 J <br /> CITY/ZtP Z n<1e'{l'�l rZ �,/ �_ ' JZ PARCEL SIZE �V <br /> il- <br /> OWNER NAME C�klNV-'I Q—it` 'f��/I <br /> JJ .��- - AODRGSS— _ <br /> CrrY/LIP C.F) / PQtIONE�t�1 — <br /> CONTRA-MR � v �J C L fes___ADDRESS Pu j� � f 7 v <br /> CITY2lPG'�a��• �- PHONES � 7 1- C-57 LICENSE!{ _EXP DATE <br /> GEOGRAPHICAL LYFORMATION: COORD12NATES X__ Y_—TOWNSHIP— RANGE T SECTION _ <br /> TYPE OF WELL: )< NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL Y_ ❑OTHER <br /> INSTALLATION: O WELL SYSTEM REPAIR ❑CROSSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELLY <br /> TYPE OF PUMP: 14EW ❑REPAIR H.P./t/ _ DEPTH PUMP SET PT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICT WELL ❑GL'OTECHNICALY O SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYP_F.OF WELT. CONSTRUCTION SPECIT(CATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DiAH CONDUCTOR CASING DIA <br /> ❑DONIEST11 13PRIVATE GRAVEL PACK/SIZE— WELL CASING TYPE � y <br /> `r" WELL CASING DIA Q _ <br /> ❑PUBLICIMUNICIPAL 13 �� <br /> DRIVEN GROUT SEAL DEPTH� SPECIKC-A}TION <br /> RIGATION/AG OTHER GROUT BRAND NAME_�I°1-tom� _ <br /> 11MONTTORLNG GROUT SEAL PUMPED: APES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE / CONCRETE PEDESTAL BY DRILLER: Fns ❑NO <br /> APPROXIMATE WELL DEPTH �� <br /> PROPOSED CONSTRUCPNOWDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND T7tA'P THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY TIIAT MY C-ST LICENSE IS CURRENT <br /> AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM DJ COMPLIANCE WITH ALI,WORKMAN'S <br /> COMPENSATION LAWS. <br /> MININIUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED E y�~� <br /> L' <br /> DEPARTMENT E ONLY <br /> Application Accepted By Date__J EMPIDY L_— <br /> Grout Inspection P I__Datey z`L�Pump Inspected By—,L1�LG�2 Date 1Z <br /> Date <br /> Tksuvction it"pection -- q <br /> COMMEN-1'S: q'2I^OZ -Li2 .borr41G SC-" GroyT scfi { G'✓F�t. P�r}RSaXJJ CovC2. c' / [QCT <br /> ��,/// •f �'_o � Gam.�R��31�^^�- �6.z�—o%a-- J J �/ 1 ✓� o!J/- / .-� t! <br /> PE SC AMOUNT HEC RECEIVED DATE REQUESIY BJVOICEY WELL <br /> CODES INFO REMITTED H BY <br /> s Lt s p .e00-'g <br /> �,eo� <br />