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%/ WELUPUMP PE <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIROA,TAL HEALTH DIVISION <br /> 304 E.WEBER AVE., STOCKMN CA 95202 (209)468-3420 <br /> y� <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS .1I 4v`,�`L L j CA <br /> PARCEL SIZE/APN r.( Y� <br /> r <br /> OWNER NAME LY UI+/I</f,b OADDRE3s� •3�S - 7—AOC)- CA 90 7( <br /> CITYra1P 'blur lm/GAwo-'%! #/7 evei-r � <br /> PHO <br /> #/7 <br /> 6XA d t,ADDRESS _ '?:r� Z-VID <br /> GEOGRAPIHCAL INFORMATION: COORDINATES Jam,,,` Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: O NEW WELL 0 REPLACEMENT WELL Cl MONITORING WELL# 0 OTHER <br /> INSTALLATION: 13 WELL SYSTEM REPAIR O CROSS-CONNECT REPAIR O VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: 0 NEW 0 REPAIR H.P. DEPTH PUMP SET_______Fr. FIRST WATER LEVEL <br /> O OUT-OF SERVICE WELL 0 GEOTECHNICAL# ❑SOIL BORING X U <br /> QED USE TYPE OF WELL N R N P I N <br /> 0 INDUSTRIAL Cl OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> 0 DOMESTIC PRIVATE 0 GRAVEL PACK/SIZE WELL CASING TYPE Sf UL WELL CASING DIA <br /> 0 PUBLIC/MUNICIPAL O DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> 0 IRRIGATION/AG 24 HR N OTl C EOTHER GROUT BRAND NAME <br /> 0 MONITORING R E Q U E STE D <br /> F(: R ALL GROUT SEAL PUMPED: OYES o No <br /> 0 CHRISTY BOX I]STOVE PIPE I N S p -1-1 N SCONCRETE PEDESTAL BY DRILLER: 0 YES O NO <br /> APPROXIMATE WELL DEPTH lrAj4A10rr✓A xQ <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER 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 ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: <br /> TITLE: ATE: <br /> DEPARTMENT USE ONLY <br /> Applicmdon Aooepted BY Date OO <br /> Are <br /> Carnot ItupecYion By Date�Pump�Pwed BY Date <br /> Destruction Inspection By <br /> ate <br /> t <br /> COMMENTS: <br /> Sa�1 It " <br /> 5 S-5b1 <br /> PE SC AMOUNT CHEC RECEIVED DATE PERmrr/SERVICE REQUEST# WELL ID# <br /> CODES INFO CASH BY <br /> o <br />