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i <br /> WELL/PUMP PERMITRRlblNA <br /> SAN JOAQl1IN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISIO <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTDN CA 93202 (209)468-3420 <br /> � NON-REFUNDABLE PERMIT EXPIRES I YEAR.FROM DATE ISSUED �J + <br /> JOB ADDRESS^2`3S6 S SO y+� &1"i F_e ROCI O A_PN Z-1 q'07D �{r <br /> CITY rzw R+u e a n k 9 S3 67 /� PARCEL,s>� <br /> OWNER NAME J u a n PC(I\i-O J q ADDRESS�2�3 Sj-ro" A VQ A%Ae <br /> CITY/LIP k=S/C-L1lON s�I�O [. �( PHONE (201)8 38-75-d , <br /> CONTRACTOR V_1'e A G �C'1 l 11't DRESS `� 1 i bW e R O qd jj <br /> Cf1Y/21P Ma <br /> L{ "S PHONE (g2S) 313 --sgO0 C-57LJCENSEN—1VSl DATE` �o <br /> GEOGRAPIDCAL INFORMATION: COORDINATES X y TOWNSHIP�S RANGE q L SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL N A OTHER (Q�I•� <br /> INSTALLATION: ❑WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR CI VAPOR EXTRACTION WEL.L0 ///��` <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑Olff'-OF-SERVICE WELL ❑GP.OTECHNICALO ❑SOIL BORING )(DESTRUCTION: Ow—Z <br /> IlYTENDED USE TYPE OF WELL CONSTRUCTION SPEMICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DiA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/STIE WELL CASING TYP11 WELL.CASING DIA _ <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEALDMTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO S7 <br /> ❑CHRISIY BOX ❑STOVE PEPE If CONCR::TE PEDESTAL BY DRRIJER: O YES ❑NO <br /> APPROXIMATE WELL DEPTH _ (� <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: M ROTARY_AIR ROTARY_AUGER SABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HA VE PREPARED THIS APPLICATION ANTJ 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 CV 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 /> 4 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED 1�rip uIGFg�„�rC .IT�-DATe b2-l�►-Zomo <br /> ' I <br /> .7a l — - -- <br /> l l <br /> 4 <br /> j11 .n - gRANCH <br /> s 5 ` <br /> } t l— 0.Y5 w.t 1 � 1 <br /> t1 + t <br /> 1 <br /> 6. <br /> 111 R�P� <br /> Z 'I f Ni RA' <br /> — �) JAN 8 <br /> r-- <br /> SAN JOAOU <br /> Cv- <br /> PUBI IC.NFAUh atkvi���„., <br /> ybS SECOR 7>3 ^�cuR � <br /> SnC PLN1 <br /> Q y 5. .�7. / <br /> CISLZ <br /> . . . #. <br /> Applitsi�!A,d p"Tudd 8'U5 D"AQI'l19NT II <br /> OMOI A� U <br /> G7cwt Impectim By Date Pump Inspected By <br /> t7uctim IncixcY y � <br /> Il <br /> MMEN!5: <br /> PE SC AMOUNT CEELKJ RECEIVED DATE PERMIT/SERVICE REQUEST 0 INVOICE 0 WELL wo <br /> CJDES INFO REMITTED CASH BY <br /> !oo— 4L,-4LWgN toSpoogq 99 '�a/-z'' <br />