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WELLTUMP PERMIT--, -- <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVI N O D <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS Z 277C) APN <br /> Cri'Y21P QCX&I2 PARCEL SIZE <br /> OWNER NAME/-!46,Xal/L'•/ Lre C ADDRESS <br /> CITY= ��d y1'tC�� / �/ r PHONE <br /> // <br /> CONTRACTORVL14 (5�� Onlz'y/�r ADDRESS (0 <br /> lE, ( <br /> C1TY/Zg)/�©OPOL<' L� PHONE37/ - l ZS C-57 LICENSE j7 �f EXP DATE�YO� <br /> GEOGRAPHICAL INFORTIATION: COORDINATES X Y TOWNSIIIP RANGE SECTION <br /> TYPE OF NVELL:>b�NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: _b4NEW ❑REPAIR H.P. 10 DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ,�4NDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA 1'6 CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE P VC WELL CASING DIA JO <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH '06 SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: lEr�ES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPES f 7-3 CONCRETE PEDESTAL BY DRILLER: 'J`❑YES ❑NO <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY� AIR ROTARY AUGER CABLE OTHER <br /> I IIEREBY CERTIFY THAT I 11AVE 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 TIIAT MY C-57 LICENSE IS CURRENT <br /> AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND TIIAT I AM IN COMPLIANCE WITII ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED TITLE QCtiE DATE SY <br /> r <br /> N�UA a �. <br /> I## <br /> DEPARTMENT USE ONLY 7 <br /> Application Accepted By Date <br /> Grout <br /> 0 L/ Area Z l EMP[D# <br /> Grout Inspection By Date J LU Pump Inspected By Date <br /> Destruction Inspection Date <br /> COMMENTS 20C/ I <br /> Grl,t/>w� S CL%AlVell S-ry-oz 73v4r S, 45�ic+csgruo ,- t/ <br /> PE SC AMOUNT CHECK# RECEIVED DATE PERM IT/SERVICEREQUEST# INVOICE# WELL ID# <br /> CODES INFO REMITTED ASH BY ' <br /> '138-V os s� S .� >� S �,o�n r3 <br />