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"tit <br />WELUPUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br />304 E. WEBER AVE THIRD FLOOR STOCKTON CA 95202 (209) 468-342p— <br />NON. <br />68-342 <br />NON- FUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUE <br />)OH ADDRESS C`f f C�. QAt.(� A —I <br />� 0 <br />IC•-r"1 <br />CY/ZIP - RCELSIZE — <br />OWNER NAME SS��2/ lJ <br />iil�( (/G _/iliv�J/ =ADDRE <br />CITY/LIP PHONE <br />CCINTRAC`MRr DDRESS 1� <br />CiTYlZIP _ HONE_-71= Cl �—C-57 LICENSE#• & l EXP DA�_ <br />GEOGRAP®CALI�TION: COORDINATES ]�_ y TOWNSHri' NCE j�jlJ I �j l' t <br />TYPE OF WFI.L:WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL#_ _ Ll Of�i <br />{I <br />INSTALLATION: EI WELL i�/LL SYSTEM REPAIR ❑CROSS-CONNECRL•PpIR ❑VAPOR EXTRACTION WELL qJf U 1� <br />MP <br />TYPE OF PU: >a/NEW ❑ REPAIR H.P. DEPTH PUMP SET <br />EJOUT-OF-SERVICEWELL ❑ GEOTECIINICAL # ❑ SOI, BORING O DESTRUC(TON: <br />D11 <br />CONSTRUCTION SPECLFIC. TION <br />DUSTRIAL OPEIVI11 <br />WELL EXCAVATION I]lA__�?L CONDUCTOR CASING DIA____ <br />❑ DOMESTIC PRIVATE ❑ GRAVEL PACFUSIZE WELL CASING TYPE , / �I WELL CASING DIA / <br />❑ PUBLICJMUNICIPAL ❑ DRIVEN <br />GROUT SEAL DEI'1'H �SPECIFICATION <br />UIRRIGATION/AG OTHER GROUT BRAND NAME <br />O MONITORING GROUT SEAT. PUMPED: ❑ YEAS prLQ0 <br />O CHRLSTY BOX O STOVE PIPE CONCRETE PEDESTAL BY DIULER: DIPS ❑ NO <br />APPROXIMATE WELLDEPTH_� <br />PROPOSED CONSTRUCTION/DRILLiNG METHOD: MUD ROTARY AIR ROTARY --AUGER CABLE OTHER <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />J40AQUIN COUNTY ORDINANCES, STATF. LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY C•57 LICENSE IS CURRENT <br />AND ACTIVE WITH THF, CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND TILAT I AM IN COMPLIANCE WTTII ALL WORKMAN'S <br />COMPENSATION LAWS. <br />MIN UNI 24 1101JR ADVANCE NOTICR REQU RED FOR INSPECTIONS <br />SIGNED <br />TITLE DATE e <br />DEPARTMENT USE ONLY <br />Application Accepted By� Dutc /19'_ — Area _EMPID# <br />Grout Inspection By� vatc / U <br />Pump Inspected By <br />Nate t <br />Destruction Inspt—tion By llntc <br />COMMENTS: OA O'f-(-- <br />1 SC AMOUNT CHECK#/ RECE I DATE PERMIC/SP.RVICEREQUESTiI [iTVOICE H ELLID# <br />CODES INTI) REMITTED CASH 1 <br />I <br />I <br />