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WELIJPUMP PERMIT <br /> SAN JOAQULN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> V)4 E.WEBER AVE.THTRU FLOOR STOCKTON CA 95202 (209)368-3420 <br /> ON-REFUNDABLE PF.RHTIT EXPIRES 1 YEAR FRONT DATE ISSUED ((11 dd <br /> JOB ADDR'SS n if-1 ._ AIXJL <br /> CrrY2fP r� L _ J PA�RCELSIZE l5 acres <br /> .a.1i�.�i-�c <br /> OWNER4ME ADDRESS <br /> TT <br /> CY/1ZIP� Y i" PHONEef IV <br /> CONTRACTOR m ' - DRESS{ <br /> CITY/Z L IQZPHONE_, —__ C-57 LICENS fJ DATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y _ TOWNSHIP_ RANGE_ SECTION <br /> TYPF.OF WELL: O NEWWELL ❑ REPLACEMF,NT WFLL ❑ MONITORING WELLN 0OTHER <br /> INSTALLATION: YO WELL SYSTEM REPAIR ❑CROSS-CONNECTREPAIR O VAPOR EXTRACTION WELL p <br /> TV./En/OF PUMP: pr NEW 0_YREEP !1{ H.PXt/y. E P MP ET F'BR3'T WATER LEVEL <br /> UTO ER tE-17 CiP.07 /HN AL so Ot� '/ O DESTRUCTION: <br /> INTENDED CSE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRP.VELPAC'K/SIZE_ WELL CASrNGTYPE WELLCAS[NODIA <br /> ❑PUBLICIMUNICIPAL 11 DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> Cl MONITORING G ROUT SEAL PUMPED: ❑YES O NO Y1( <br /> O CHRISTY BOX O STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEI'IH <br /> r <br /> PROPOSED CONSTRUCTIONIORILLING METHOD Ml;U ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY TTIAT 1 HAVE PREPARED THIS APPLICATION ANTJ THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY C-57 LICENSE IS CURRENT <br /> AND ACTIVE WrITI THE CALIFORNIA CONTRACI'ORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WTTH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> 1N1 111 4 HOUR ADVANCF,?OTICE RE LIRE FOR INSPECTIONS z <br /> SIGNE LL — ITTI-E - <br /> S <br /> " _ I <br /> -- - <br /> I CD <br /> -� •- a <br /> E y) <br /> �� J(pn(', f1�� DEPARTMEYI'USE ONLY 1 1 1 1 n4 <br /> Appliatino Acccp[CC By T1.11,A7�i OVAJ_ _. _Date - 1 Z" Area -L__BMPWt{1-.t S <br /> Grout Inspmtion riy—_ Dale_ Pump Inspe'ed By <br /> Destruction Inspection By - .Date <br /> COMMENTS:____ <br /> !'ESC AMOl1Ml' HECKF/ RECEIVED DATE PCRMITISERVU'L•REQUEST M INVOICE WELL11Jtl <br /> CODES INFO REMRTED BY <br /> i3go 050 1113 a;Il)RO02 8 ^�3c: <br />