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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 /> y <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ✓ I ZX V ' �'� CA <br /> PARCEL S2UAPNN CITY/ZIp <br /> OWNER NAME <br /> ADDRESS <br /> Ti�'f CA 9J 3 74C <br /> CITY/ZIP 199/QA-7a•,-) S617 L+ vel-r I bp / <br /> t <br /> PHONE <br /> / p <br /> CONTRACTOR SPEC/e'IM G,l(lP/--0'<,ADDRESS �d p 3 Z' /O <br /> CITY/Zip 1-157C 'e` ,'/ 2 -6 00 PHONE " 4-6 5 Y 7/ 2- <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 /> Q OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING )(DESTRUCTION: <br /> XM <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION wd 9-A PCA) <br /> ❑INDUSTRIAL Cl OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL.PACK/SIZE WELL CASING TYPE SrE1 C WELL CASING DIA!'/ Z !r <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG 24 I--i R N CTI C EOTHER GROUT BRAND NAME <br /> ❑MONITORING R E Q U E STE <br /> F(:]R ALL GROUT SEAL PUMPED: 13 YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPEI f� CTI O N SCONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPTH CrkjCNUi/ <br /> Ay <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY OR.DIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: <br /> TITLE: DATE: O <br /> E <br /> DEPARTMENT USE ONLY <br /> Application Accepted By 4k- yy�II,I Dat-11 <br /> ate Uv Area <br /> Grout Inspection By Date B 11 I Ih Pump Inspected By Date <br /> Destruction Inspection By ` II" Date <br /> COMMENTS: ipfw -1LkW IV— <br /> 5b�f I 'Abo 5 5-Sal <br /> PE SC AMOUNT -- CHECCAV RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# <br /> CODES INFO REMITTED CASH BY <br /> y3,7q r8 0? a o z3 -7 0 <br />