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WELL/PUMP PERMIT SAN JOAQUIN NTY PUBLIC HEALTH SERVICES ENVIRONME EALTH DIVISION 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ]OB ADDRESS I� c /LLOGLI �E PARCELSIZEJAPN'./-139-02,0- d3 dCITYIZIP STdd'� �N OWNER NAME �o �&tP�+ ADDRESS X a CITY/ZIP 3�C.�mN.�/GA- �/'S 'Z-O�PHONE CONTRACTOR ��^'y�T fh97/Y1AT ADDRESS o/L) /7Q�r �O CITY/ZIP'ay-AA f2VA 0�-� �YZ PHONE Lv/�/Ill — GEOGRAPHICAL INFORMATION: COORDINATES X_ Y_ TOWNSHIP_ RANGE_ SECTION TYPE OF WELL: ❑ NEW WELL 13REPLACEMENT WELL MONITORING WELL# /AI6C-L� ❑OTHER INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING Cl DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIAA�jO J CONDUCTOR CASING DIA�4 ❑DOMESTIC PRIVATE 13 GRAVEL PACK/SIZE_ WELL CASING TYPE /rG WELL CASING DIA ,L i ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH — SPECIFICATION 6� ❑IRRIGATION/AG OTHER GROUT BRAND NAME MONITORING GROUT SEAL PUMPED: ❑YES <NO KCHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES XNO APPROXIMATE WELL DEPTH 740 PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY_AIR ROTARYI HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND _AUGER CABLE_ OTHER JOAQU N COUNTY ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS GULATIONS O AACCORDANCE WITH SAN N JOAQUIIN COUNTY, SIGNED: X71 !,®/"'S. TITLE: /S=LL' `�•��yTrs� DATE: DEPARTMENT USE ONLY Application Accepted By Dat Area Grout Inspection By Date 0 Pump Inspected By l Date Destruction Inspection By Date COMMENTS: PE SC AMOUNT CHECK#/ RECEIVED DATE PERMIT/SERVICE REQUEST# WELL I CODES INFO REMITTED CASH BY so I •©o (� �o (�C of Seo6s�