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t WELL/PUMP PERMIT <br /> \{� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> v n 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 <br /> I <br /> IW-C0 S / NON-REFUNDAB�LE,,PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS J�4 �I�CH�� t�c�2K r-}N C SITS AJ�izS� APN (33"ZO <br /> -04 <br /> C <br /> CITY/ZIPOLK,�%�1 CA Z PARCEL SIZE_ <br /> OWNER NAME 115�,L kM- t- � �10 SADD11%Dk5REF_SS SS_ -7 <br /> Lt�j Lou fJ (=TIZ <br /> CITY/ZIP 'St0(-KTz3j CA <br /> OEr",t <br /> a0 <br /> , N <br /> L <br /> CONTRACTOR Vj ADDRESS Z'I 3 T <br /> kje[ TcSCITY/ZIP HONE S 13 Z <br /> �{O <br /> C-57 LICENSE# ZCC�04EXPDATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# J6 OTHER 01- <br /> INSTALLATION: <br /> yINSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL ± 1 -7 <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# WISOIL BORING L" -� �% ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION , 1 <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA I.5 " CONDUCTOR CASING DIA fJ`Fk <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE N/A WELL CASING DIA �/A <br /> ❑PUBLIC/MUNICIPAL ®DRIVEN GROUT SEAL DEPTH -rarAL SPECIFICATION 1,11A <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO t4 <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ©NO <br /> APPROXIMATE WELL DEPTH 10 - ( <br /> S 1 G- _�i203t <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER yC <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 j <br /> SIGNED ' `c".� `-' L — TITLEDATE <br /> blc1lJ l o <br /> DEPARTMENT USE ONLY <br /> Application Accepted Be�y//,, Date 6 N & Area EMPID# <br /> Grout Inspection By 44<,,� Date "L n( Pump Inspected By Date <br /> Destruction Inspection By Date <br /> COMMENTS: <br /> PE SC AMOUNT CHECK#/ RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL ID# <br /> CODES INFO I REMITTED CASH BY <br /> 901 `�a° lib � l 4 OU <br /> F-1 <br />