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WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 70B ADDRESS PARCEL SIZE/APN CITYIZIP '4 OWNER NAMEI x ;:-�' =t a J g ADDRESS ` CITYIZIP PHONE 7 J 1 CONTRACTOR ADDRESS CITY/7-IPPHONE GEOGRAPHICAL e GEOGRAPHICAL INFORMATION. COORDINATES X V TOWNSHIP RANGE SECTION TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# OTHER INSTALLATION: 0 WELL SYSTEM REPAIR D CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL#� TYPE OF PUMP: ❑ N ��; � `� � ❑RPAIR H.P. DEPTH PUMP SET NT. FIRST WATER LEVEL ❑OUT-OF-SERVICE WELL 0 GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA ❑DOMESTIC PRIVATE ❑GRAVEL PACK/S1ZE WELL CASING TYPE WELL CASING DIA ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION ❑IRRIGATION/AG 24 HR " I 'HER GROUT BRAND NAME EUEE� MONITORING F C)R GROUT SEAL PUMPED: ❑YES ❑IVO 0 CHRISTY BOX ❑STOVE.PIPE S R E STI(D"SDNCRETE PEDESTAL BY DRILLER: ❑YES ❑NO APPROXIMATE WELL DEPTH PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER- � I I4EREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. �-' SIGNED: f TITLE: " DATE: f i I m i 3 i I JLI EL:l ' � I i - I _ i E ' [ i ' I l I J il2iii I DEPAR'T'MENT USE ONLY f Application Accepted By I' F z` g Date_? Area Grout Inspection By Date Pump Inspected By 7 Date t Destruc€ion Inspection By _ Date COMMENTS: PE Sc AMOUNT CHECK#1 RECEIVED DATE PERMIT/SERVICE REQUEST# WELLID# CODES INFO REMITTED CASK BY F ;