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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 <br /> JOB ADDRESS S S APN 0?®-15 <br /> CITY/ZIP / /�/� PARCEL SIZE <br /> OWNER NAMEfq' k^�I zo `�L/1e ADDRESS <br /> CITY/Zlp ��` �f f PHONE <br /> CONTRAC/TAOlR��� 61ZSS YJizlZIZIL —ADDRESS I <br /> CITY/Zlfl�&00 ll��Ll L PHONE. )S/ ( 7 ZS C-57 LICENSEk 220 EXPDATE(!�; 0- <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL:7<l NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: _1n::-NEW ❑REPAIR H.P. ID 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 /> INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA l'6 CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE P VC WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH '2-06 /SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <f to:Oe� <br /> ❑MONITORING GROUT SEAL PUMPED: trYES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE j 73 CONCRETE PEDESTAL BY DRILLER: J`O YES ❑NO <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTION/DRILLING METHOD'MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN w <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 TIIAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS / <br /> SIGNED /^ TITLE Off ' DATE S l <br /> 4�56 =A _�:z <br /> NVA <br /> J <br /> N U <br /> :# DEPARTMENT USE ONLY 7 <br /> l L/ � <br /> Application Accepted By � �°� Date Q Area Z )� EMPID# <br /> Grout Inspection By Date /U__�ZPump Inspected By Date <br /> Destruction Inspection (n� Date A <br /> COMMENTS: EC i V k l C, <br /> (ilt/IULiI S i C�'1�-1 kvI <br /> v,6-1 S 1v'DZ q 73 CdEJ.L Rau T' <br /> PE SC AMOUNT CHECK# RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL ID# <br /> CODES INFO REMITTED 7ASH BY <br /> y3� �j/C_ , q <br />