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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)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED V °L <br /> JOB ADDRESS Llr.[ CL t.��C K L/ AIN <br /> CTFYlZip �" �`JPARCEL SIZE <br /> OWNER N WE O✓ �. f <br /> ADDRESS <br /> CTI'Y/LB' 1--4)/� PHONE h <br /> CONTRACTOR-A 1 C_A L L ADDRESS-P440 <br /> CIP1'(ZIP�/d��� / 4- PHONE 7a�_T 7 4'�� C-57 LICENSF , _EXP DATE ` <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y TOWNSHIP- RANGE_ SECTION <br /> TYPE OF WELL:�>< NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL p ❑OTHER <br /> INSTALLATION: DWELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL Is <br /> MP _ <br /> TYPE OF PU : -2NEW O REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL Y ❑SOIL BORLNG ❑DESTRUCTION: <br /> B\TENDED USE UU OF WELL CONSTRUCTION SPECFFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DLA CONDUCTOR CASINO DIA <br /> ID DOMESTIC PRIVATE ❑GRAVEL PACK/SME, WELL CASING TYPE WELL CASING DIA _ <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEALDP.PTHSPECIFICATION <br /> 6RIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: APES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL PEDESTAL BY DRILLER: PES ❑NO <br /> APPROXIMATE WELL DEPTH `7 Z S <br /> PROPOSED CONSTRUCnON/DRII.LING METHOD: MUD ROTAR y,X AIR ROTARY AUGER CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPA RED THIS APPLICATION AND THAT TTIE WORK WILL BE DONE IN ACCORDANCE WMI SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY C-51 LICENSE IS CURRENT <br /> AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORIL%IAN'S <br /> COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED-FORINSPECTIONS <br /> SIGNED �.�Ci[/`fJ" -ti""" T!fLE DATE <br /> I I I <br /> R <br /> I <br /> c. r <br /> / DEPARTMENT USE ONLY <br /> (_ <br /> Application Accepted By I14/--- ) Date / �J �n Anal-a -.-EMPB�NN <br /> Gtnut Inspection Py 1�1. ,i��f' Date �+y Pump Inspccted By ,i�r _Datef¢/aT <br /> Destmction In;pectim Date q <br /> COMMENTS: Y 2`'/4z ✓FRto+(/S CouCk�9Ze •S Y• / l S <br /> �4���c O w Gw„_a! G�tI� ..✓r n /Y+-.�rro/ .r�1 s ✓ O >/ �l/i../1✓ <br /> PE SC AMOUNT HECK RECEIVED DATE PERM MSERVICEREQUEST II INVOICE# WELL <br /> CODES IN REMITTED H BY <br /> 3 6-75__ s py 23 J <br /> .r�,r2OTJ o2q�� <br />