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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)465-3420 Aga ■ <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED 77 <br /> " Q P� <br /> JOB ADDRESS '7 �L 7<' Va 44/ APN <br /> ` CITY/LIP .�IOG/i �� �� .� PARCEL <br /> SSIZE <br /> OWNER NAMEG45 f 11 C/T�`� /Ci ADDRESS 7/-2yVLI/Iyy-��Y'J7,J <br /> CITY/LIP Ci/c?rgfj ? —PHONE_._1,0VK 3 yc�fi' <br /> CONTRACTOR ADDRESS <br /> CITY/LIP PHONE C-57 LICENSE# EXP DATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y_ TOWNSHIP_ RANGE_ SECTION <br /> TIN TYPEOF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL#___—��-[_ETHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. 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 CONDUCTOR CASING DIA <br /> MESTICPRIVATE ❑GRAVEL PACKISIZE_ WELLCASINGTYPE WELLCASINGDIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN " ��� GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROAT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE tj CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> :r. <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTION/DRIII NG 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 <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 THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> MIN ^^ nnHOUR ADVANCE NOTICE REQUIR <br /> E <br /> D FOR INSPECTIONS t� <br /> SIGNED "'_�' - TITLE Pt�✓/1 P� DATE—L- <br /> 114 <br /> ATEL-// t <br /> U <br /> PARCEL 1 <br /> P OSEV Lai use <br /> 0 <br /> ra O LOT u,[ <br /> z <br /> J <br /> PARCEL 2 <br /> [aao uca[a <br /> � a S <br /> LOT LIK TO <br /> �0a01 <br /> Ittlf � <br /> ♦wsa.way \—�' __ — __ <br /> r aw CPEEY` (SOUTH BRANCH) <br /> DEPARTMENT USE ONLY <br /> Application Accepted By t. ' Date I /! Area I L� ,Date_MPID#5 P <br /> Great Inspection By J Da[e�/_L Pump Inspected By Date <br /> Destmction Inspection By �/f (J Date / (� /., <br /> COMMENTS: .�I /�ILCx.! �tR' /'I ka � 1i�� L 1 —1 J � '" <br /> PE SC AMOUNT C RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL TD# <br /> "DES INFO REMITTED CASH BY <br /> ? 7 <br /> N �J' zz <br /> 37 5� 8�5 <br />