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WELIJPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 952112 (209)468-3420 <br /> NON•REFUNDAB E PERMIT IRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS A APN S�'–fyi�— 7 <br /> ITI <br /> I <br /> CYIZIP I— PARCEL SIZE <br /> :OWNER NAME ASS �O d a n 1 ADDRESS_!-1 <br /> CR'Y2Ip !��0 17 t PHONE �� SZ� <br /> CONTRACTOR ay�J�r TADDRESS . - I <br /> CnY/ZIp PHONE L'-57 LICENSES EXPDATE <br /> GEOGRAPHICAL INFORMATION:COORDINATES X— Y TOWNSHIP_ RANGE_SECTION <br /> TYPE OF WELD ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELLS ❑OTHER I <br /> i <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECF REPAIR ❑VAPOR EXTRACTION WELLS <br /> TYPE OF PUMP: ❑NEW ❑REPAIR H_P. DEPTH PUMP SET FT'. FIRST WATER LEVEL <br /> I <br /> OUT-OF-SERVICE WELL ❑GEOTECHNICAL S ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WEI,I. CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DLA,— <br /> C3 DOMES71C PRIVATE <br /> IA❑DOMESi1CPRIVATE ❑GRAVEL PACK/SIZE_ WELL CASING TYPE WELLCASINGDIA <br /> ❑PUBLICIMUNICIPAL [3 DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATIONIAG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES a NO <br /> I <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO t <br /> I <br /> APPROXIMATE WELLDEF17H <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY_AUGER CABLE=OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND TEAT THE WORK WILL BE DONE IN ACCORDANCE WITH;SAN O' <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 WOM MANS <br /> COMPENSATION LAWS. <br /> MINIMUM-24 HOUR ADVANCE NOTICE REQUIRED FOR INSPEC'T'IONS <br /> 3lGNED_ t! —! Zsr TITLE <br /> I I ! ^ <br /> I <br /> I <br /> i <br /> I i <br /> I 4t i <br /> I I t <br /> I IA <br /> I <br /> I I <br /> I I <br /> i <br /> i ' I <br /> 4 <br /> I ' <br /> I <br /> DEPARTMENT USE ONLY f <br /> Application Acxp[ed By Zk[e ca I t" MPIIM /t I <br /> Grout Inspection By Date PumpJnspx[ed By [hte <br /> Destruction Inspection By paw <br /> COMMENTS: <br /> PE Sc AMOUNT CHECKS/ RECEIVED DATE PERMITJSERVICEREQUEST B INVOICES WELLW# <br /> CODES INFO REM CASH BY <br />