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WELL/PUMP PERMIT <br />. <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVLS <br />304 E. WEBER AVE, THIRD FLOOR STOCKTON CA 95202 (209)468-3420 <br />NON.REFUNIDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS 300 Ot S PO APN 1 1 2.O f <br />CITY/ZIP <br />- <br />ELL <br />OWNER NAME J. 5i&lokAy-0 4 Sk;k-g <br /> PARCEL SIZE <br />ADDRESS 2-C1.0 Ct. Peck 54-4-1(-4, <br />crro-zip_S— <br />CONTRACIOR. ADDRESS_ <br /> PHONE 2, -2-0 3 <br /> <br />;cfppzipe..A1 3bie; III ',1 CO . PHONE 3381 - 03'4 ? C-57 LICENSE* 43 e1-2-1 cXP DATE 0 . 4. i i Ila Y TiA V I 0 R'.. CA ,/ _5-3 sco ' <br />GEOGRAPHICAL LNFORNIATION.: COORDINATES X Y TOWNSHIP RANGE SECTION <br />TYPE OF WELL: 0 NEW WELL 0 REPLACEMENT WELL 0 MON noR ING WELL* 0 OTHER <br />INSTALLATION: D WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL* <br />TYPE OF PUMP: 0 NEW 0 REPAIR II.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br />X OUT-OE-SERVICE WELL El GEOTECHNICAL* 0 SOIL BORING 0 DESTRUCTION. <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION 0 INDUSTRIAL 0 OPEN R(I lOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br />0 DOMESTIC PRIVATE 0 GRAVEL PACK/SEE WELL CASING TYPE WELL CASING DIA <br />0 PUBLIC/MUNICIPAL 0 DRIVEN GROUT SEAL DEFTH SPECIFICATION <br />0 IRRIGATION/AG <br />moNrroRING <br />0 CHRISTY BOX 0 STOVE PIPE <br />APPROXIMATE WELL DEPTH <br /> <br />011IER GROUT BRAND NAME <br /> <br />GROUT SEAL PUMPED: 0 YES 0 NO <br />CONCRETE PEDESTAL BY DRILLER: 0 YES 0 NO <br /> <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 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 />SIGNED <br />MIN UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br />e..-- <br />- TITLE_ _ DATE <br />. MMMIIIMMMIMMMIMMM MMMINIMM UMMINIM 211,AMMMIMMOmmIMMM MIME allOMMUMMIIMO .... ........, ... ...N. ummemm _ <br />1%1 <br />Elm... ...... ......m......m.... MOMMO.OM MAIM. MOM= MOM <br />iii Ina Alp,. IIMIIIIII <br />ilimmom millimailim ... MEM : 1 .1. .........I. <br />Applicanoo Accepted By <br />Grout Inspection By <br />Destruction Inspcction B \ <br /> Date <br />COMMENTS: I nt, 2-06 — <br />Q0477:5/ <br />C LO __PEDES <br />SC <br />INFO <br />AMOUNT <br />REMITTED <br />CHECK / <br />BY <br />REC • ' ED DA PER MIT/SERVI REQUEST <br />..... iNcygcE # <br />...- <br />OM <br />WELL ID* <br /> rig" /00e. 4092_ c-tel, '12-0/0-f <br />_ (L,37?e=i9,a_P-711.3 <br />' PAO . MIME... m .2......... <br />Fir7I .MMENSIMME 11111=112fig m• <br /> OMMI m. ..OMMEN 11111== MUER w........ 4VINT <br />Date <br />DEPARTMENT USE ONLY <br /> Date f/z,/cr Area 2(q EMMA <br />Pump Inspected By Date <br />„ r4 a