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w WELL/PUMP PERMIT <br /> SAN JOA91UN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTON CA 95202 (209)468-3420 <br /> G NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS_��/e� OF, f t/%�OPJ Gi'! r' �'f APN ;- �13 -.2061 -el <br /> / <br /> CITY/ZIP / t?-,4rC�Q22"5'3-3 7 - j PAR/CEL�SSIZE f F►� a G <br /> OWNER NAME —?,7,f Cl/2 -e-/ 15'ryXX�TU�/5ADDRESS h / J7bg�4 ✓9 /YI� <br /> CITY/ZI_ I�G P5 T4 / 3 �� PHONE <br /> CONTRACTOR Lf�I�I/-4 G., --.ADDRESS 19V ' 21L <•T <br /> CITY/ZIP L S�� T021 42 �6 PHONE '�b ZZZ !L4Zg&2 C-57 LICENSE4 EXP DATE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP S RANGE SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL lj MONITORING WELL# ❑OTHER <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# ❑SOIL BORING 0 DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA if CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑,GRAVEL PACK/SIZE WELL CASING TYPE �� G WELL CASING DIA <br /> i <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH 3 SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> Gl MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPTH (cJkv I,l,T 7a h e �t fy5?r�r!� �,� •ae`�. �";'F �jlrx�7/�c <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER_� J <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 DATE �Q Z <br /> ormer arlson nlckmg raclllty J <br /> r I 9909 East Woodward Avenue <br /> S&;3 Approximate Lateral Extent of GW Diesel Plume Manteca.CA 95366 <br /> Drainage Pond <br /> ® ssv <br /> MW <br /> Li •Monnonn`WNI L­_ <br /> Pole Bam HB.I .Bm"sS=Ple Locmon <br /> ® al swop <br /> NW <br /> sBe <br /> •h"A S&5 Repair Shop/Garage <br /> SBS • <br /> MW-= Fomes w—ol I:STL_ <br /> ® 5811 SB•I. 'I ' <br /> Si.t?omggc Wu Weil 0 <br /> DEPARTMENT USE ONLY <br /> Application Accepted By � v( Y, ., Date „ ..��' Area EMPID# I TO6 <br /> Grout Inspection By Date Pump Inspected By Date <br /> Destruction Inspection B Da <br /> COMMENTS:_ <br /> I ' pec <br /> PE SC AMOUNT CHECK#/ RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL ID# <br /> CODES INFO REMITTED CASH BY <br /> L9q TV ” <br />