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WELL/PUMP PERMIT ! <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTII DIVi <br />304 E. WEBER AVE. THIRD FLOOR STOCKTON CA 95202 (209) 4b8.3420 <br />WELL <br />NODI -REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS_ 6T: 13i;ee <br />CIT YIZIP % PARCEL SIZE <br />OWNER NAME ezeJV, he- dc-%v.317eL0CTiO4) ADDRESS %`?) edel-re?y4.j <br />CfTYrLIP�!%9TiFDNr�L1'e� (°.y. 9.1077-JQ_,e PHONE(-P.31'74,3'G,z0n <br />CONTRACTOR ,V ADDRESS_Q)<) ul. G r rrr <br />AYNI1=(V <br />CITY/ZlPLzA7edL_y.yd. Csi. yJ'6S PHONE6 -3G' ,e."n2-G.79. C-57 UCENSEMI f4 , A TE <br />GEOGRAPHICAL INFORMATION: COORDINATES X_ Y TOWNSHIP RANGE SECTIO FE ` Q0 <br />TYPE OF WELL: M NEW WELL ❑ REPLACEMENT WELL 13 MONITORING WEI.L#i__ `1AW15i?Ji#1-6� _ ---- <br />FL'ELIG 1iFALI4 SERVCF' <br />INSTALLATION: ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR O VAPOR EXTRACTION WELL 71i0PENPLNIA' H� ICN f'dlrS. it <br />TYPE OF PUMP: ❑ NEW O REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br />❑ OUT -OF -SERVICE WELL ❑ GEOTECHNICAL p ❑ SOIL BORING O DESTRUCTION: <br />I1�_ FD USE TYPE OF WELL CONSTRUCTION TR N <br />M INDUSTRIAL ❑ OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br />❑ DOMESTIC PRIVATE M GRAVEL PACK/STLE WELL CASING TYPE iSreed- WELL CASING DIA <br />17 PUBLIOMUNICIPAL ❑ DRIVEN GR OUT SEAL DEPTH SPECIF7CATl0 <br />/D S�C�sv y <br />❑ IRRIGATION/AG 3 <br />J OTHER GROUT BRAND NAME <br />CI MONITORING GROUT SEAL PUMPED: 0 YES O NO <br />❑ CHRISTY BOX 11 STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑ YES ® NO <br />APPROXIMATE WELL DEFM glop• <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY ✓ AIR ROTARY AUGER CABLE OTHER <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WELL BE DONE IN ACCORDANCE WTTH SAN <br />JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY C-57 LICENSE IS CURRENT <br />AND ACTIVE WTTII THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKMAN'S <br />COMPENSATION LAWS. <br />MINIMUM 244 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED- L • (/ 'L -yLS:e / � !G ��� TITLE__ DATE a��%-/ <br />T I- <br />IF <br />• - -I - <br />DEPARTMENT USE ONLY <br />Application Ace"ted By Date �S Area w f EMPu-)# / <br />Grout Inspection By Da 7'' Pump Inspected By Dare <br />Desuvcuon Inspection By Dau <br />COMMENTS: <br />PE <br />SC <br />AMOUNT <br />C <br />RECEIVED <br />DATE PERMIT/SERVICE RE UE M INVOICE M <br />WELL ID# <br />CODES <br />1N PO <br />REMrITED <br />H <br />BY <br />110 <br />coo.js <br />R <br />