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I• 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 /l��1/J9Y/,v <br /> PARCEL SIZE/AP//N�J'UTY� N� CITY/ZIP A/ <br /> OWNER NAME(cL7L 01s-z+c/LRL& ADDRESS yL� /" <br /> CITY/ZIP �' GrDi� PHONE <br /> CONTRACTOR y' ✓S-� �,,�� -�/�T� ADDRESS 3233 �TyG7f��� � <br /> CITY/LIP � ��� /� 95✓YLPHONE �996J <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y_ TOWNSHIP_ RANGE— SECTION <br /> TYPE OF WELL: C NEW WELL ❑ REPLACEMENT WELL x MONITORING WELL# .Ll6�G❑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 ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION /�'- <br /> 13 INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA <br /> N,Ad CONDUCTOR CASING DIAD <br /> ❑DOMESTIC PRIVATE , MRAVELPACK/SIZE_ WELL CASING TYPE WELL CASING DIA d. /t <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH 1_ SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> )(MONITORING GROUT SEAL PUMPED: ❑YES NNO <br /> CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ANO <br /> APPROXIMATE WELL DEPTH Yoe <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY_AIR ROTARY_AUGER y 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 ANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: l A <br /> TITLE: I� Ilir//T ���i�T/7/ DATE: <br /> \ , DEPARTMENT USE ONLY <br /> Application Accepted By Date 6 _Area <br /> Grout Inspection By �J.� DatePump Inspected By (- <br /> Destruction Inspection By Date <br /> COMMENTS: <br /> PE SC AMOUNT CHECK#/ RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# <br /> CODES INFO REMITTED CASH BY <br /> %Z' o a R G6 <br /> ll� <br />