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WELL/PUMP PERMIT 01.3z mo� <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE.. STOCKTON CA 95202 (209)468-3420 PAYMENT <br /> . ,QANON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE c RECEIVED D. <br /> JOB ADDRESS ' 1 N o � G <br /> PARCELSTLFJAPN_��fr ._CrrY/LIP /0 SAN IQA0 <br /> 5 C'D L�r��� a ADDRESS_ f , PUBLIC HEALTH SERNCES <br /> OWNER NAME �I 7 ENVIRONMENTAL HFALTH n-SIO!4 <br /> CITY ZIP r + PHONE �4 7 — ! 7 O / <br /> CONTRACrOR e n ' / ADDRESS [nA E� �O.l� 9S�j 3� _ <br /> Crryrap �f4/� (�A�t PHONE+ &l x779 <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y_TOWNSHIP_ RANGE—SECTION <br /> TYPE OF WELL: V"WELL 0-REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: E NEW ❑REPAIR H.P. DEPTH PUMP SET fay FI. FIRST WATER LEVEL2 <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA,Z;�� CONDUCTOR CASING DIA <br /> MESTIC PRIVATE C3 GRAVEL PACK/Sim—ALWELL CASING TYPE_&.9 WELL CASING DIA0_ <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH a 490o SPECIFPI^CATION f�/y�8y <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME /.s s9 ( L�A/te <br /> 24 l---Cam i•.�C�{CE ,,t�� <br /> ❑MONITORING R E . Q GROUT SEAL PUMPED: fn O ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE PC:)!--I ^L L CONCRETE PEDESTAL BY DRILLER: SES ❑NO <br /> APPROXIMATE WELL DEPTH 1 -TI C'N'S/ <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY v 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 /> TTI.E: jolt,2 - DATE: <br /> W <br /> -- __ D TMENTUSEL]NLY._ <br /> Application Accepted By74Area_ <br /> Date <br /> Grout Inspection By Date O W- 'o Pump Inspected By Date <br /> Destruction Inspection By Date <br /> COMMENTS: <br /> PE SC AMOUNT ECK#/ RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# <br /> CODES INFO BY <br /> y 3 �Z- g' <br />