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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-REFUADAB E PERMIT E IRES 1 YEAR FROM DATE ISSUED I; <br /> JOB ADDRESS Ac APND S�= /1 rl7— � <br /> CI7Y21P � PARCEL SIZE--a2_6 C re'_—_- <br /> OWNER NAME ASS �O 2 6 d✓1 I ADDRESS ! .Sj_-S <br /> Crryalp ��o n i PHoxE 36 `I �Z6 6 <br /> CONTRACTOR A0 6C r 4 "&-!I <br /> ADDRESS ._ <br /> I <br /> CIIY2IP PHONE C-S7 LICENSE# EXP DATE <br /> GEOGRAPHICAL INFORMATION:COORDINATES X__ Y TOWNSHIP_ RANGE_SECTION <br /> TYPE OF WELL: 0 NEW WELL 0 REPLACEMENT WELL 0 MONITORING WELL# 0 OTHER j <br /> INSTALLATION: O WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL* <br /> TYPE OF PUMP: 0 NEW 0 REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> i <br /> OUT-OFSERVICE WELL 0 GEOTECHNICAL# O SOIL BORING O DESTRUCTION: <br /> INTENDBD USE TYPE OF WFIA CONSTRUCTION SPECIFICATION <br /> 0 INDUSTRIAL 0 OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> 0 DOMESTIC PRIVATE 0 GRAVEL PACK/SIZE_ WELL CASING TYPE WELL CASING DIA <br /> 13PUBLICIMUNICIPAL 13 DRIVEN GROUT SEAL DEPTH SPECIFICATION__ <br /> 0 IRRIGATION/AG OTHER GROUT BRAND NAME <br /> O MONITORING GROUT SEAL PUMPED: 0 YES ONO <br /> I <br /> D CHRISTY BOX 0 STOVE PIPE CONCRETE PEDESTAL BY DRILLER: OYES 0 NO <br /> I <br /> APPROXIMATE WELL DEPTH — �y]}I <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 O' <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 CON"TRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> MINIIMUMA 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED. �? ..� '� TITLE ___. DATE <br /> i <br /> r— I <br /> I <br /> 1 <br /> iv 17 <br /> A NA <br /> I I i <br /> F RD MFId Al HF i i NL 0:. <br /> DEPARTMENT USE ONLY / <br /> Application Accepted By to Area t' EMPID# He 1 <br /> Grout Inspection ByDate Pump Inspected By ____._ Date <br /> Destruction Inspection By- Date <br /> COMMENTS: <br /> PE Sc AMOUNT HE K#/ RECEIVED DATE PERMrI/SERVICEREQUEST# INVOICF,* WELL ID# <br /> CODES INFO REM CASH BY <br />