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' VPELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIMS <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 <br /> f ELL <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS '300 S . APN 1 q— 12-6 —( f <br /> CITY/L[P w <br /> � j� + _ PARCEL SIZE <br /> OWNERNAME V`5[ti�L1W xkl l� 1 ADDRESS lrC�� l I f uL (-p_M� �o% ` <br /> Clr /ZpB J -OC,k—iD v\ a S HONE J-L Z—20 3 z_ <br /> CONTRACTOR ADDRESS s � <br /> r V V\ � � 1 6 PHONE CA ol� C-57 LICENSE#3 T��rZ!"EXP DATE <br /> lT r 2-- <br /> GEOGRAPHICAL LNFORMATION: COORDINATES X Y TOWNSHIP_ RANGE_SECTION <br /> TYPE OF WELL: ElNEW WELL ❑ REPLACEMENT WELL [II'T <br /> MONI'T'ORING WELL# _❑OTHER <br /> INSTALLATION: O WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP; ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FP. FIRST WATER LEVEL <br /> ROUT-0F-SERVICE WELL 13GEOTECHNICAL# ElSOIL BORING ❑DESTRUCTION: <br /> TfENDED USE TYPE OF WELL CONSTRUCTIONS EC1FI ATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DJA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELLCASING DTA <br /> ❑PUBLIC(MUNFCIPAL El DRIVEN GROUTSEALDEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPTH <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-87 LICENSE 1S CURRENT <br /> AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WTTR ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> MINI UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED L <br /> 17TI.E— DATE )-d J <br /> n <br /> I - <br /> - I <br /> a <br /> - I <br /> i <br /> 4-4 <br /> r t-1vll,A�,-NI';t :Id <br /> DEPARTMENT USE ONLY <br /> Application Accepted By EMPIDft� <br /> Grout Inspection By <br /> Date Pump inspected By _Date <br /> Desttuclion Inspection B Date _ <br /> V COMMENTi;_ H LQ 5 C Z LC! <br /> PE SC AMOUNT' CHECK#/ RL( ED DA PERMIT/SERVI EREQUEST* INV ICE <br /> S` CODES INFO REMITTED By WIJi.ID# <br /> a <br /> o <br /> C. rril yam. C7 <br />