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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBHC HEALTH SERVICES ENVIRONMENTALHEAL9'H DIVISION <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468.3420 PUMP <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> J03 ADDRESS 27-770 5 . "(-r ­jj�,\AJC. APN <br /> CITYIZIP �ra.GV ��]. �� PARCEL SIZE <br /> OWNER NAME Fre, k tle1 Rs ADDRESS <br /> CR'Y/LB'_ __ _PHONE SSS-75yId <br /> CONTRACTOR_��tiS ��rr{�IG ADDRESS ?O 7?�,=,Y \SG <br /> (:rry2lp Tr xcY Q 7i 7 _PHONE_PHONE C ZC*i) F3 S-22A_'A —C-S7 LICENSE# 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 O CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELLY <br /> TYPE OF PUMP: NLNEW ❑REPAIR H.P.-1 7- DEPTH PUMP SET 130 PI'. FIRST WATER LEVEL <br /> ❑OUT-0F-SERVICE WELI. ❑GEOTECHNICAL#--- O SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN B(YITOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> DOMESTIC PRIVATE ❑GKAVEL PAMSIZE WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEALDPJ'TH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROU"BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> O CHRISfY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPI'H___LjLA `I- _ $C <br /> PROPOSED CONSTRUCPIONIDRILUJNG METHOD: MUD ROTARY AIR ROI ARY AUGER CABLE__OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PRFPARED 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 CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. O n <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS 7A <br /> SIGNED-- TTTLE��� Tech DATE <br /> LA <br /> .-Y <br /> 11 f.P1N ,. <br /> DE TMENT USE ONLY <br /> Appticauon Accepted By - —Date Area lD# <br /> Grout Inspection iiy, Date Pump Inspatcd B _Ur <br /> Destruction Inspection By. Date <br /> COMMENTS <br /> PE F-Sc AMOUNRECEIVED bATE PERMIT/SERV T# INVOICE# WE:LID# <br /> CODES I INFO REMITTED BY <br />