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WELL/PUMP PERMI <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 <br /> G� NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED 2 [� <br /> JOB ADDRESS/ (�� 1_' v�EST Q pv�J R-D APN z�7� `�`�C') r L 2' <br /> CITY/ZB' _�'� ��t"GZ_ / PARCEL SIZE 4`Z /� <br /> OWNER NAME DSS R)"©(U'P1'_ %ADDRESS 23,33 t l I 1/ Ind I <br /> CITY/ZB' e r 3 PHONE <br /> CONTRACTOR ! S t� �G I I' ADDRESS 11 q,14 eg <br /> 1 CITY/ZIP J PHONE)22"'192 C-57 LICENSE#aaP EXPDATE <br /> i <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION�F'AYM�7EI�1( <br /> RECiz vEE <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# MAR 15 200 <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WAIW�ftN COUNTY <br /> ENVIRO ENTAL HEALTH L)1VISfON <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING �ESTRUCTIONi <br /> j INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ii ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPEYTea - WELL CASING DIA <br /> i ❑PUBLICIMUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> 1 <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> I <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPTH <br /> i PROPOSED CONSTRUCTIONIDRILLING 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 /> MINIMUM <br /> UUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> i <br /> SIGNED ��C`C- G�2[l/J e-(G� TITLE N G/[IZ� DATE-3-J,5 a 1 <br /> i C <br /> F. <br /> f <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date `-i- I Area Z EMPID#g3_t4 <br /> Grout InspectionB Da� Pump Inspected By Date <br /> Destruction Inspection By Date <br /> COMMENTS: E✓ll <br /> flA_12YAW -b\4 PUMP <br /> PE SC AMOUNT CHECK#/ RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL ID# <br /> CODES INFO REMITTED CASH BY <br /> q�1'� ( AM <br />