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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 306E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 � <br /> r ' <br /> 54� NON-REFUNDAB I PERMIT E BFS 1 YEAR FROM DATE ISSUED {�^/�^ / <br /> JOB ADDRESS / L[_ <br /> CIIY2@ L.0 C PARCEL SE L77 Ac -l:- <br /> OWNER NAME 14`S 00 I d a n i ADDRess 1 3!4 4 N- �o��d <br /> crrrrzn- k o.1 1 / PxoNe 3A 4 Szd 6 <br /> ^ <br /> CONTRACTOR No�]c I� , ADDRESS C <br /> CITYADP PHONE C-SILICENSEB EXPDATB <br /> GEOGRAPHICALINTORMATION: COORDINATES X__ Y TOWNSFDP_ RANGE_SECTION <br /> TYPEOFWELL: ❑ NEWWEIL ❑ REPIACEMENTWEW ❑ MONDORINGWELL# ❑OTHER <br /> INSTALLATION: ❑WELLSYSTEMREPAIR ❑CROSS.CONNECi REPAIR ❑VAPOREXTRACFIONWELLY i <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPOT PUMP SET F[. FMSTWATERIPVEL <br /> DVI'-0PSERVICE WELL. 0GE07ECHNICALP ❑SOS BORING _ ODESIRUCf10N: <br /> INTENDED USE TYPE OF WALL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL 13 OPEN BOTTOM WELLEXCAVATIONDIA CONDUCTORCASINGIXA <br /> ❑DOMESTICPRIVATE ❑GRAVEL PACX/SIZE WELLCASNOTYPE WE.LLCASINGIRA <br /> ❑PUBLK7MUNICIPAL ❑DRIVEN GROUTSEALDEPI71 SPECIFICATION <br /> ❑BUOGATIOMAG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUTSEALPUMPED: ❑YES ❑NO <br /> I <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRHLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCION/DRILMG METHOD MUD ROTARY_AIR ROTARY_AUGER_CABLE_OTHER_ <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THIN WORE WDLL BE DONE IN ACCORDANCE WITH SAN O' <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS 1 ALSO CERTIFY THAT MY C-5'J LICENSE IS CURRENT <br /> AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WOERMAN'S (:i <br /> COMPENSATION LAWS C <br /> MINIIMUM-24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS I <br /> SIGNED Y� 776.8awLy DATE <br /> Y n� <br /> 41 <br /> I <br /> I <br /> 18 <br /> P HFt"I <br /> I <br /> ' DEPARTMENT USE ONLY i <br /> I <br /> APPH.U.A.MaI By Dale ILS nMamu__j�_- _ I <br /> Groes hlsPection By no- Pump bwe BY 0.Y <br /> I <br /> DGSW[YOO IusPCCtiae By DY@ ' <br /> COMMENTS: <br /> PE SC AMOUNT M/ RECEIVED DATE PFRMIF/SERVICEREQUEST# INVOICE# WELLI)11 <br /> CODES INFO REM CAS BY <br />