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I <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PUMP <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95702 (209)468.3410 <br /> NON-REFUNDABLE PERMIT VAMPS I Y AR FROM DATE LSSUEDD <br /> !OB ADD ESS Lno K471ne, VtjAPN V5l -, I <br /> C[TYrLIP V r T-_- - P�ARC,{ELSSII}ZE <br /> OWNER 4ME I <br /> CITYILLP��� --L �- 'JJ�� _PHONF. -I l U��.7 <br /> CONTRACTOR- r-AN r UDRES,0 - <br /> CITY l q,:544-PHONIi.�d�- It C-57 LIC£NSFB Saar DATE . <br /> GEOGRAPHICAL INFORMATION:COORDINATES X_-. Y-------IYIWNSHD'---„ RANGE.,_-- SECTION_-_-,-,,,-_ <br /> TYPE OF WELL: O NEW WELL O REPLACEMENT WELL O MONITORING Cl Q OTHER <br /> INSTALLATION: O WELL.SYSTEM REPAIR O CROSS-CONNECT REPABt IJ VAPOR EXTRACTION WELL# - - - <br /> f <br /> TYPE OF PGMP. V NEW O REPAIR H.P. DEPTH PUMP SIT_.---PI. FIRST WATER LEVEL <br /> 0 OUT-OF-SERVICE WELL O GF.OTECHNK AL#_ _ O SOIL BORING L3 DESTRUCTION: _ <br /> INTENDED USE I=OF WELL QQN5TKTMON�StSMICATION <br /> O INDUSTRIAL O OPEN BOTTOM WELL EXCAVA77ON DIA CONDUCTOR CASING DIA <br /> 93 DOMESTIC PRIVATE 0GRnVELPACK/SIZE_ WELLCASINGTYPE WELLCASIIGDIA <br /> O PUBL10MUNICIPAL O DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> P IRRIGATION/AG OTHER GROUT BRAND NAME <br /> O MONITORING OROUTSEAL PUMPED: O YES O NO <br /> O CHRISTY BOX O STOVF-PIPE CONCRETE PEDESTAL BY DRILLER: 0 YES O NO <br /> APPROXIMATE WELL DEPTHY,_-.---- _ <br /> PROPOSED CONSTRU(TION/DRILING METHOD•. MUD ROTARY_AIR ROTARY_AUGER_CABLE_OTHER <br /> 1 HEREBY CF:RTIYY THAT 1 HAVE PRF'PARED THIS APPLICATION AND THAT TIB.WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS.I ALSO CERTIFY THAT MY CST 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 LAWS. <br /> luNI Z4 HOUR DVANCE N,OTICB REQUIRED FOR INSPECTIONS ` .D <br /> SXNNED L>' �- TITLE _ DATE,�,,,f_ - <br /> r <br /> i r <br /> r <br /> P j �IMPARIM <br /> ff USE ONLY <br /> Applicauvn Accepted By- ---- ----------Date_ S Anal BMPID# + . <br /> Grave Inspoction By -_�_.--- Dare -J'ump Inspected B �l>u -ice <br /> Lksmicrioo In.vwtiun BY J __-_ --- Date� <br /> COMMEW.S: <br /> S'E SC AMOUNT CHET RECEIVED DATE <br /> I <br /> CODES IN F0 REMITTED C SH BY - QUEST N INVOICE N WELL IDN <br /> i <br /> 380 a5o 5b j IN o sii~Gb�S�S�oL 3,3�/ <br /> I <br /> I <br /> I <br /> L. <br />