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b� WELL/PUMP PERl1''1IT <br /> SAN JOAQLIN C'OUNJ Y PURI IC ILEALTI1 S _RbiCFS FNV[RONMFNTAI.HFALTH DIVISION <br /> A04 F..WEBLR A%'L., STOC'KTON CA O;20? i_'09)408-3420 <br /> C NON-REFUNDABLE PERMIT EXPIRLS 1 YEAR FROM DATE ISSUED €� <br /> (JIi ADQ.RFt457 f r �i.� f=_ �� �C3 tJ e-C'_ , ss CSA A <br /> PARCEL SIZE/APNC ��'i' 0 ) — CITY/2IP_- <br /> OWNER N'AMF A49 1 G ADDRESS <br /> CITY/2IP_ I rfley � �� Fr ) PHONE <br /> I V <br /> CONTRACTOR!�� E „� � I��r ADDRFSS� - <br /> CITY/ZIP—S 6L �e., SCS PHONE q <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 D REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED OE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> O INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION IIA K q–6 CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZB WELL CASING TYPE WELL CASING DIA <br /> Q PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROU"I'BRAND NAME C'e,,e,.s, 4- <br /> 0 <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> O CHRISTY BOX ❑STOVE PIPE CONCRLTE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUINCOUNT RDIANCES,STATE LAW <br /> S,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: _ <br /> OOF <br /> TPI'LE: 1 DATE' <br /> i'�TTw <br /> `.? 4.4 <br /> LYiM>Vnts �\ <br /> a,n y i ea s a Ii A O <br /> ;NEA 11r Ai ovu <br /> TRACT <br /> TrLEA - 2.2 <br /> ISt urP - 3-2 1 <br /> BRACH TRACT <br /> Al <br /> IT I <br /> F=_� - S 7EAL/fNOV5 <br /> - .tlr,nii <br /> [L loo 9 <br /> -ROULOIN -'- �T. �rdAOr <br /> ' - IRAQI <br /> P <br /> DEPARTMENT USE ONLY <br /> Application Accepted �r � Date J�•21��� rhea �(� <br /> Grout Inspection P, It+.� Inspected By Date- <br /> Destruction Inspection By Date <br /> cohmlErrrs: UfA4-d yrew e4f" '1;e'wa lyiY4 <br /> PE Sc AMOUNT RECEIVED DATEPE VICE REQ # WELL M# <br /> CODES INFO REMITTED C SH BY <br /> X13 2M2 M2 '� p 2 19/ <br />