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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE„ STOCKTON CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED / <br /> JOB ADDRESS is r(r/& <br /> PARCEL SIZE/APN _ CITY/ZIP f+ � Q <br /> OWNER NAME Gp/�`L;Ne+N Qom.-- ADDRESS S -7�y �7 f hL� <br /> CITYfLIP `d3[$MLN 1U 7 PHONE(9/(O'y) / L�7' (AD <br /> CONTRACTOR—CAL� I` ADDRESS_ / <br /> CITY/ZIP 'lii�52 759 k 7 PHONE h <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP �"' LANA-6SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# _Q OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW 0 REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL A"EOTECHNICAL# _ ❑SOIL BORING T ElDESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZEWELL CASING TYPE WELL CASING DIA <br /> ❑PUBLICIMUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG 24 }-IR N aTl 6HER GROUT BRAND NAME <br /> O MONITORING R E L�U ESTE I]GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPEFC;I� L_L_ CONCRETE PEDESTAL BY DRILLER: ❑YES 0 NO <br /> INSPECTIpNS <br /> APPROXIMATE WELL DEPTH _ <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY�IR ROTARY AUGER 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 ORD STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: _ <br /> TITLE: �[y C V CD -11'-[�G SKATE: �!� <br /> 41 <br /> rra <br /> il IV <br /> Ma <br /> u <br /> IMT <br /> s <br /> Fa $ <br /> �• �' y+� roman Rd. <br /> Ewoadwu*d Avdi <br /> w Wwnt.aea��04'ODZ <br /> Am <br /> LL. <br /> I <br /> DEPARTMENT USE ONLY �,7 <br /> Application Accepted'By Date—4 -8 -3~3 .'area 'LN q )It <br /> Grout Inspection By Dat Pump Inspected By Date. <br /> Destruction Inspection B ate <br /> COMMENT'S: <br /> Ger/�� �J ��'�� ^�C,— c�✓ <br /> E SC AMOUNT HEC RECEIVED DATE SERVICEREQUEST# WELL ID# <br /> CODES INFO REMITTED BY <br /> z30 00334- 0 25-0� <br />