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PAYMENT <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E_WEBER AVE., STOCKTON CA 95202 (209)468-3420 0 C T 2 6 2000 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOACUIN COUNTY <br /> JOB ADDRESS CC�sZ r LI HEALTH SERVICES <br /> �' O� '�I iId NV SION <br /> PARCELSIZEIAPN Aff--.<. +- CITY2IP JAG�-T <br /> Al-.4 rSc�r4 GOrLl�� <br /> OWNERNAME GSC ADDRESS r <br /> CITYIZIP_ PHONE T T: rt` C .17 f J - y rT Y 7 <br /> CONTRACTOR_�4IE1 j R� fiIIJ��Sd 't�[f�CADDRESS <br /> CITY/ZIP _Cr f Z-¢O PHONE 3�� I <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: -*'NEW WELL ❑ REPLACEMENT WELL ❑ 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#1 KSOIL BORING El DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> INDUSTRIAL L OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE J WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH " I SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME (3U -7C-- X�:,�Z-_F <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES O <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES f❑NO <br /> APPROXIMATE WELL DEPTH r <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER 74 <br /> CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED, •421 i ��-+ / r <br /> TITLE: i rl r r-I i DATE: -z-5 OCa <br /> 1 <br /> T <br /> a <br /> r � <br /> C <br /> i <br /> l , <br /> DEPARTMENT USE ONLY O 3^/' <br /> Application Accepted By Dale —Area �a <br /> Grout Inspection By Dal d 'OoPump Inspected By Date_ <br /> Destruction Inspection By ale <br /> COMMENTS: r VJK M <br /> PE SC A UNT CHEC RECEIVED DATE PERMIT/SE T# WELL ID# <br /> CODES INFO REMITTED CASH BY <br /> 45U t'z )-SD- Fes& a <br />