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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)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �7 <br /> JOB ADDRESS V�r \Ser C� APN_ <br /> CITYfZ PP�0��� O�� Q��•�S -7 <br /> OWNER <br /> \1 PARCEL SIZE �j <br /> OWNER NAMJE S� �1�.��\����,�LADDRESS <br /> CTrY/ZIP O �`�.. ��� PHONE <br /> CONTRACTOQR �n��V2��A� L\C \�AD1D1RESS,`\(��C� VO <br /> PHONE "1�`1• `1 4�q C-57 LICENSE# CC k- EXP DATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <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 /> "`A <br /> DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE �. WELL CASING DIA <br /> ❑PUBLICIMUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE -\ CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPTH ��'� <br /> PROPOSED CONSTRUCTION/DRILLING 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 24 HOUR ADVANCE NOTIC . SQUIRED FOR INSPECTIONS \ l <br /> SIGNED\\ ` ` a ��. TITLE O� DATE `� V <br /> S <br /> Z <br /> LF41.N <br /> F C <br /> i <br /> 4_1 ELL- ##-++ <br /> c <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Z G Area /At EMPID# t�L/ <br /> Grout Inspection By Date Pump Inspected R, ez /,� 22:� <br /> Destruction Inspection By Date <br /> COMMENTS: <br /> PE SC AMOUNT ECK RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL ID# <br /> CODES INFO REMITTED CASH BY <br /> �s `� <br /> 149 1 <br />