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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVE <br />304 E. WEBER AVE. THIRD FLOOR STOCKTON CA 95202 . (209) 4684420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS .0(:) q, Po CL LAI-n 6 • APN 17.61-/ W —/ I <br />crnmp 51-OC.L1-071 PARCEL SIZE 23 ik. <br />OWNER NAME5L/551-) -K.- 5 Z ADDRESS 6285 q Ca r0c/(r) CIL • <br />ciTy.eolcm la-1 o, ir LD • ci# ... fo -6-3/-gclo,7e— 9216 <br />coNTRAcroi; L - 0 /GO (:)..teK Orliff/V ADDRESS 30 5 • i ' 1 I ireiL9 <br />CITY/ZIP lial 6' C r q.5--8,e) PHONE (a62 '2- '742* eq C-57 VelagEXP 3 LICENSES/ DATE <br />GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br />TYPE OF WELL 0 NEW WELL 0 REPLACEMENT WELL 0 MONITORING WELL 4 0 OTHER <br />INSTALLATION: CI WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL 0 <br />TYPE OF PUMP: 0 NEW 0 REPAIR FIR DEPTH PUMP SET Fr. FIRST WATER LEVEL <br />001ST-OF-SERVICE WEI 1 0 GEOTECHNICAL 0 0 SOIL BORING iDESTRUCTION: ce ffi-e il-7-eii"Crie. <br />INTENDED USE TYPE OF vvEiJ. 64:6.1 A5 It t t-Y <br />CONSTRUCTION SPECIEIMM <br />CI INDUSTRIAL O OPEN BOTTOM WELL EXCAVATION VIA_____ CONDUCTOR CASING DIA_ <br />0 DOMESTIC PRIVATE 0 GRAVEL PACK/SIZE WELL CASING TYPE WELL CASING DIA <br />0 PUBLIOMUNIOPAL 0 DRIVEN GROUT SEAL DEPTH SPECIFICATION <br />CI IRRIGATION/AG OTHER GROUT BRAND NAME <br />CI MONITORING GROUT SEAL PUMPED: 0 YES CI NO <br />0 .CHRISTY BOX 0 STOVE PIPE CONCRETE PEDESTAL BY DRILLER: 0 YES 0 NO <br />APPROXIMATE WELL DEPTH <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br />I HEREBY CERTIFY THAT! 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 LICENSEE 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 />6--3/--/ SIGNED " r' 7TTLE 5 ectrieds DATE <br />ill.... ime••• =mom c IMMO MIMI .UNE MEM <br />poWl= MIMI ( <br />raltRaIr INININIEZiki- MI WM 4.111/4 <br />, Nu <br />NOM= <br /> 16 _. • i P. .... <br />MIIMi:ai nip1=1111•111111 . 110.1 -.0 <br />Pl. r in ,PAy RAE -1'v -F- <br />ti FOP VED 7 <br />1i4± I 1 <br />. .„_a_c_11:11____ <br />sm JOAQUIN±,-.9 LINT- . PALI HEALP1ER F 4.1ilrbM t/'a ,A 1,97H _CF.,' nirw <br />if DEPARTMENT USE ONLY <br />Application Accepted 0y Date sin I 01 Are... D-11 ENPID4 i <br />Grout Inspection By Date Pump inspected By Date <br />Destruction Inspectioa i <br />,44er . r2 2.--- ,-",?x„.",„" / •. , , Date <br />COMMENT'S. -2 wet II 4-., Cle34 I p'd <br />17---4--- <br />II e s P7 e tikt i ei-Li )`t- c <br />:ir ' ..... .,,-. • . , ... - <br />6.02;,-,...' -4%-- (71•(--) ."0 -. A?, 70t, .4cp A--,---e-,--s.e.,•,-7-- •••• HE—C---;451(4/ PE <br />CODES <br />SC <br />INFO <br />AMOUNT <br />REMITTED f <br />RECEIVED <br />BY <br />Min ,../ PER REQUEST 4 INVOICE if WELL ID* <br />1-1371 I fp f I so°° /6 -311M Ge ) (44?;?-/DI 21 1 Fc 7 S7)41 a <br />11373 1.CO\ Rot <br />SR 00,9-'7 / ? 7 ( S P 0 0-2:7 i c' 8"