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WELL/PUMP PERMIT 70--ZD o I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE.,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 5 M S <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1 (� <br /> JOB AUURESS I Zt) l APN 1 O 3� <br /> CITY/ZIP- C S- Z PARCEL SIZE y Z` <br /> OWNER NAMES jV /Ll ADDRL'SS wt-.'e- Gk pi �gS2 0 �p <br /> CITY/ZIP I _ .. PHONE <br /> CONTRACTOR e!—�_rN�l�(rA_ ,,yA�DDRE.SS <br /> CITY/zIP S F"TC N PHONE! �y$''!3 y Ste— c-s�LICENSEa y� - 3XP DATE I e <br /> GEOGRAPHICALINFORDLITION: COORDINATES X----- Y TOWNSHIP RANGE___— SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITCIRING WELL# ❑OTIIER <br /> INSTALLATION: DWELL SYSTEM REPAIR ❑CROSS(.ONNECi'REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PLWi : ❑ NEW ❑REPAIR H.P. _ DEPTH PUMP SET FT. MRST WATER LEVEL _ <br /> ❑OUT-OF-SERVICE WELL GEOTECHNICAL# ❑SOIL HORING _ O DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECrFIC.AT'ION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WEI1,EXCAVATION DIA ( CONDUC`TOR CASING DIA_ <br /> ❑DOMESTIC:PRIVATE, ❑GRAVEL PACK/SIZE_._ WELL CASING TYPE -_-_ WELLCASING DIA <br /> ❑PUBLI OHNICALaN pRIVEN GROUT SEALDL17H SPEJCIFICATION <br /> ❑IRRIGATION/AG OTWUROU`EBR!ND NAME <br /> ❑MONITORING cIRUIIT SEAL Ml TESTING ❑YEs ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE i11OWDEPTH 7� Z-57 ` <br /> Q <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE,PREPARED THIS APPLICATION AND THAT THE WORK 1WILL BE DONE IN ACCORDANCE:WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULFS AND REGULATIONS. I AI SO CERTIFY THAT MY C-57 LICENSE IS CURRF,NT <br /> AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> i11I OUR ADVANCE NOTICE. REQUIRED FO INSPECTIONS g��-� <br /> SIGNED 1 TITLE l <br /> Z <br /> — r� <br /> ..,,., - <br /> .,h.. <br /> CN I <br /> .L <br /> t a <br /> 1 _ <br /> L =° Lo <br /> M M. Tr. I <br /> 01ti4 � It <br /> I — I <br /> — — Lid <br /> ty t <br /> ,', r' <br /> DEPARTMENT USE ONLY <br /> Application Accepted —By �� 9 J -Date Q Area�,�--_EMPID# <br /> spection y DatE��`�o/ Pump Inspected By Datc <br /> �.� 1 I — <br /> Destruction Inspection By _.,, NO CHF-MICAL TE Date __ <br /> .00 <br /> COMMENTS: � 8_o�� i oI Com _... �� <br /> PE SC AMOUNT I CIIECK#/ RECEIVED DATE INVOICE# WELL ID# <br /> CODES INFO REMITTED BY <br /> � 2— K6 2-9L)0' / <br />