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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> � ) Q ,304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 <br /> � 15R )NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATF <br /> � iCCiTCT <br /> JOB ADDRESS_ Jt AITIV-H U30a-K` ?LAN- /�7 <br /> CITY/z>P Sroc-cz�t'j ,CA 15 203 <br /> /!-, ^^�. PARCEL SIZE_±S Ia L- GS <br /> ld5AL lr � -�cJ rC/O ADDRE S��C 1+ <br /> OWNER NAME <br /> CITY/ZIP ` t0<_1< baJ CA ONE <br /> CONTRACTORy VJ 1C�=ll. �r L O I>H �J1 L <br /> ADDRESS Z`737 LEJMEMAO�J 4= F)2L-kc) <br /> crrY/zlP4t 53 PHo E &69 S 69 CIA 3 '1 ZO�i <br /> C-57 LICENSE# EXP DATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# J11 OTHER Bb%IN EY <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 } d <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# wsoa BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA , �• CONDUCTOR CASING DIA 1 <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE i,J/A WELL CASING DIA ��A <br /> ❑PUBLIC/MUNICIPAL E DRIVEN GROUT SEAL DEPTH 'rUT" " SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAMES <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO r.1, <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES 0 NO <br /> APPROXIMATE WELL DEPTH 10~ (S f <br /> &C-b ,-?12a3t <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER >C <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 /> SIGNED T <br /> TITLE �- ' ST DATE 0401 l.3( 0 <br /> f,1' <br /> Q DEPARTMENT USE ONLY <br /> Application Accepted By Date b / Area_ EMPID# <br /> Grout Inspection By Date Pump Inspected By Date <br /> Destruction Inspection By Date <br /> COMMENTS: <br /> PE SC AMOUNT CHECK#/ RECEIVED DATE <br /> CODES INFO REMrrTED CASH BY PERMIT/SERVICE REQUEST# INVOICE# WELL ID# <br /> Sol 0226 y5-7 <br />