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WELL(PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 364 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 =9)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> IOB ADDRESS lfjyL fi(p R �'`1 APN L <br /> CITYfLIP Z3 ARCELSIZE <br /> OWNER NA A R S <br /> CITYlL1P PHONE. <br /> CONTRACTOR DRESS t <br /> CIT]' &64 1-?— sswc-57 LICENSE&--k PDA <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y TOWNSHIP_ RANGE_SECTION <br /> � I <br /> TYPE OF WELL: V [YEW WELL 0 REPLACEMENT WELL ❑ MON[TORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL k <br /> TYPE OF PUMP: 2i NEW ❑REPAIR H.P- DEPTH PUMP SET FT, FIRST WATER LEVEL <br /> ❑OUT-0P-SERVICE WELL ❑GEOTECHNICAL C SOIL BORING ❑DESTRUCTION: <br /> CONSTRUCTION SPECIFICATfON <br /> IN//DUS�RV+L O�M WELL EXCAVATION DIA,- CONDUCTOR CASING D[A <br /> 9'D6MESTIC PRIVATE ❑GRAVEL PACK/SME WELL CASING TYPEi�LGt• WELL CASING DIA J1 1 . <br /> 11 / <br /> LICJMUNICIPALGrr��j4`��' ❑DRIVEN GROUTSEALDEPII•I SPECIFICATION <br /> IR <br /> 0 RIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: / <br /> ❑CHRISTY BOX ❑STOVE PIFE CONCRETE PEDESTAL BY DRILLER: SES ❑NO <br /> APPROXIMATE WELL DEPTHX�/ <br /> PROPOSED CONSTRUCITONIDRII.I ING METHOD: MUD ROTARY AIR ROTARY_AUGER CABLE Y OTHER <br /> i <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 TEAT MY C•57 LICENSE IS CURRENT <br /> AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLU►NCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS <br /> MINIMUMHOUR ADVANCE NOTICE REQ- R INSPECTIONS <br /> SIGNED TITLE 07A DATE Ij/(// <br /> I <br /> i 1 <br /> IN(ZI <br /> , <br /> I ' <br /> { i ' <br /> i I <br /> i 11 <br /> i <br /> i <br /> i I <br /> i �IVI O M N <br /> I � , <br /> i <br /> -- <br /> Apptieauan-Ac-pla0 <br /> Grout Incpcc By to%_ P <br /> DesttxUcmm Inspcctioa By �~. Da <br /> COMMENTS:a'a-&Jey/ <br /> PE SC AMOUNT CHECK RECEIVED DATE /PERMTTISERVICE EQUESTm INVA'CEk WI.L.L[bk <br /> COIFS INTO REMITTED CASH BY / .L��•w .( i /�, �' <br />