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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL'HEALTH D <br /> jl 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 ©L„1 <br /> 1 ] NON-REFUNDABLE PE IT EXPIRES 1 YEAR FROM DATE ISSUED yam/ `� <br /> JOB ADDRESS_] i r C�:IM ^�t r✓ chi 's OLP o <br /> ij APN <br /> CITY/ZIP <br /> PARCEL SIZE ,i/f' r.✓Sf.i'��____ <br /> OWNER NAM�E/�!°x'�7 ti S +�G�'Ili:C f�V ADDRESS ` �/t� �, iJ �'n 6�� {�. /J©�[ 1?--0 <br /> CITY/ZIP._ /"L �lI -C'C� i� 9 S�3 p PHONE 3 <br /> ff II <br /> CONTRACTOR I� ,ys^ 1 Vyc� (Y G -elll` ADDRESS �C� � �, � CCij� f�t� I <br /> CITI/ZIP C. u✓ �I .1 PHONE t' J �� _ a <br /> C-57 LICENSE# EXP DATE <br /> Ij <br /> 0 <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y_ TOWNSHIP RANGE SECTION <br /> i <br /> TYPE OF WELL: 0 NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: O WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: .0 NEW j� ❑REPAIR H.P. �' DEPTH PUMP SET a FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> Ir <br /> INTENDED USE ! TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> 13INDUSTRIAL i 0 OPEN BOTTOM WELL EXCAVATION DIA " CONDUCTOR CASING DIA <br /> WDOMESTIC PRIVATE X'GRAVEL PACK/SIZE WELL CASING TYPET WELL CASING DIA <br /> rti <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH r O V <br /> SPECIFICATI _.0- <br /> i SS <br /> CIRRIGATION/AG OTHER GROUT BRAND NAME Pa <br /> ❑ �— <br /> , <br /> MONITORING li GROUT SEAL PUMPED: WYES ❑NO <br /> jl <br /> O CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES 4d NO <br /> APPROXIMATE WELL DEPTH II C7rj <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY ROTARY AUGER CABLE OTHER i <br /> .jl � <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 /> l <br /> COMPENSATION LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIR FOR INSPECTIONS <br /> SIGNED i �� 7 Com------ — TITLE DATE �CJoZ <br /> 4 <br /> t <br /> -c ` <br /> f� <br /> �. <br /> I + <br /> U C <br /> :- --= ---e .- .- <br /> _1 _04 - -DEYA-RTNIENi'USE-ON;/7/3TP <br /> Application Accepted By Date y Area EMPID#G % <br /> Inspection <br /> p <br /> Date c-,X Pump Inspected yf = Date <br /> Grout Ins <br /> Destruction Inspection By ! I) , Date <br /> COMMENTS: <br /> s: <br /> it <br /> PE SC AMOUNTEC ' 1 RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL ID# <br /> CODES INFO` REMITTED SH BY <br /> 2 2 c?0-5 5 <br /> I� <br /> I� n <br />