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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 �CI AY 2 2 Z 0 01 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED_ <br /> JOB ADDRESS 17 123 ti rt V APN <br /> CITY/ZIP � e -� PARCEL SIZE <br /> OWNER NAMM�jE J 'c ADDRESS / 32 7 f KA I�, � py�� <br /> CITY/Z l't g2�C'�G ,I / S�_3 PHONE 2`'-/ <br /> CONTRACTOR Z M .vd u5 t r(­S 7-we--ADDRESS 5 Y S 4-/ UC6l1L) <br /> y✓D PHONE C-57 CITY/ZIP s C-57 LICENSE# EXP DATEkAo-_OJ <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 ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING lig ESTRUCTION: �✓0-1 e5 "1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELLCASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN , GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG I Z OTHER GROUT BRAND NAME <br /> ❑MONITORING I GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPTH 71 <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 <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 LAWS. <br /> MINIMUM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> -�-• DATE-S--22- <br /> SIGNED &'-t <br /> TITLE <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Dat, ~' AreaoL EMPID# <br /> Grout Inspection By ���/�l�E!'`�� DatePump Inspected By Date <br /> Destruction Inspection By e <br /> COMMENTS: <br /> PE SC AMOUNT CHECK#/ RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL ID# <br /> CODES INFO REMITTED CASH BY <br /> 3'f3 ( coo°— <br /> __ . - � --- vas*+ - • <br />