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WELL/PUMP PERMIT <br /> SAN JOA(, =NTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTL__.ISION <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 <br /> NON-REFUND BLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j7. <br /> JOB ADDRESS /�EAST NWDAVA/RA BLE <br /> UE APN Z� <br /> CITY/LIP MATE-eA PARCELSIZE <br /> OWNER NAME H'49� ns<-c LL. <br /> R T �hIN to <br /> qq ADDRESS a5 N: S4 NcbL SrRt�T <br /> CHY/LIP 4.7,01 C, A -/5a.A40 PHONE <br /> CONTRACTOR V 4k W -tUl JA16"y' ADDRESS PC' F-,OX 5/ <br /> Crry/z P —PJP vts>r PHONE C-57 LICENSE#1 Z C"EXP DATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y TOWNSHIP_ RANGE_SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# 0 OTHER P1103t; <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 <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# M SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> 1l <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA s CONDUCTOR CASING DIA MIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELL CASING DIA NSA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH r'3 L✓ SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME N6 V-TLA)jD <br /> ❑MONITORING GROUT SEAL PUMPED: 19 YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑Nq�&NSA <br /> APPROXIMATE WELL DEPTH 2 O <br /> PROPOSED CONSTRUCIION/DRI.LING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> \,t I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> k 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 /> t��r .......-... <br /> � - COMPENSATION LAWS. <br /> 1 _MINIM. UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> { SIGNED TITLE VL ,�t 1�� DATE C\ ZL OQ <br /> D <br /> A i <br /> _:#4X-L-,7J <br /> T. <br /> el -44- <br /> n <br /> f '����. DEPARTMENT USE ONLL healArea—EMPID#_ApplicationAcceptedBY )U4 r• v•'� Date / <br /> Grout Inspection By t Pump Inspected By' Date <br /> r <br /> Destruction Inspection BY Date <br /> 1COMM a 1 y} <br /> 1) 1 ✓'. 7 <br /> v r <br /> PE SC AMOUNT CHECK#/ RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL IDM <br /> CODES INFO REMITTED CASH <br />