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WELL/PUMP PERMITS <br />SAN JOAQ*OUNTY PUBLIC HEALTH SERVICES ENVIRONMEATALDIVISION <br />304 E. WEBER AVE, rr FLOOR STUCKTONi 09468-3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROMDATE ISSUED <br />•: ADDRESS <br />• i r <br />•--ADDRESS <br />crry/z PHONE <br />CONTRACTOR c5r,60 F4 rr• <br />crry/zip d 1—PHONE r• <br />GEOGRAPHICAL INFORMATION: COORDINATES X_ Y — TOWNSHIP— RANGE SECTION <br />INSTALLATION: ■ WELL SYSTEM REPAIR ■ CROSS-CONNECT REPAIR■ VAPOR E TRACTION <br />TYPE OF PUMP: 13 NEW 13 REPAIR H.P.—WA DEPTH PUMP SET FF. FIRST WATER LEVEL— <br />■ • • ■ GEOTECHNICAL El SOILBORING . ■ r • <br />INTENDED USE TYPEOF 1 •N SPECIFICATION <br />■ INDUSTRIAL ■ OPEN BOTTOM WELL EXCAVATIONDIA CONDUCTORi r <br />0 DOMESTIC PRIVATE 13 GRAVEL PACK/SIZE WELL CASING TYPE— WELL CASING DIA <br />13 PUBLIC/MUNICIPALPUBLIC/MUNICIPAL • DRIVEN GROUTSEALDEPTHi • <br />13 ■i • OTHER GROUTr <br />13 MONITORING GROUT SEAL PUMPED: HI YES 13 NO <br />11 CHRISTY BOX ■ STOVE PIPE CONCRETEr r•i ■ YES WNO <br />APPROXIMATE WELL DEPTH <br />PROPOSED CONSTRUCTION/DRILLING METH•r r ROTARY AIR .• OTHER <br />APPLICATIONI HEREBY CERTIFY THAT I HAVE PREPARED THIS •• DONE INACCORDANCE <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 <br />MIN�lmr 2 HOUR DV NCE NOTICE REQUIRED FOR INSPECTIONS <br />SIGNED ��, <br />- - - / - - <br />■■MMMMM■■■■■■■■wT�zrr��r�r�nr�ra�■r�r�r�!w■■■■w■■■ <br />■■■■■■■■■■■■ ■�S i�W�iili�ffii(■frriir■�■■■■■■■■■■■ <br />■■�■■N■■■■ ■■www■■w�■■��ww■wwl�ww■■.■■ww�:cisi■■ <br />N■■■%Mai 1� ■■N�■■■■■1■■■■�■����■ ■■■�liir�'i■■■■ <br />■■��%/%%I/,� ■���r�rN■rte■r�N��rr�■ �■'iL:■1►11�■■■■ <br />■■■�NN■■■■■■N■■■w�Io7�����wA��!991�L'�'7►1►�1i 3��ir,�1■■■■ <br />■N■■NN■■■■■■■■LCI �l'J►L'Z!1/���_�'�liZ�3�Jl �i%ri0�'C�I�■■■ <br />■■■� nor`P.:IfJ�■i��l�t�!L!�iiN■■■■■■■■■■■■■■■■■N■■■ <br />■�■�■■■■■■■■■III /I ■■■■N■■■■■■■■■■■■■■■■■■■ <br />DEPARTMENT USE ONLY <br />Accested B 'I", do, FF —Date Area EMPID# <br />InspectionA-ij-dication <br />Grout By Date—Pumpr. <br />Destruction Inspection By ---Date <br />. ► �JIIJ <br />