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- � 1 <br /> 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 /> NON-REFUNDABLF.PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS � OF O -OUD41 <br /> PARCEL SEMAPN 17 1,�cveS CITYIZ1P <br /> OWNER NAMA/1 ADDRESS !�//'' <br /> / /// t <br /> 74/ <br /> CITYIZIP NN C off-- . A(PHONE � / VZ <br /> ' CONTRACTOR IK ADDRESS <br /> CICYlLIP. ✓Ft PHONE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y TOWNSIIIP_ RANGE_SECTION <br /> TYPE OF WELL: XNE.W WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL-t <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑OEOTECHNICAL it ❑SOIL BORING ❑DESTRUCTION:_ <br /> INTENDED USE TYPE OF WE LL CONSTRUCI'JON SPECIFICATION <br /> ❑INDUSTRIAL 0 OPEN BOTTOM WELL EXCAVATION D Q CONDUCTOR CASING DIA <br /> D4QMESTICPRIVATE �4IRAVELPACKISIZE_ WELL CASINGTYPE_tj!2'_ WELLCASINGDI <br /> ❑PUBLICIMUNICIPAL ❑DRIVEN GROUT SEAL DEPTHf <br /> 1,12a_— SPECIFICATION <br /> ❑IRRIGATION/AG 24 "R N CTI C E OTHER GROUT'BRAND NAME Aly AA- <br /> 13MONITORINGR E Q U E S_rEE p GROUT SEAL PUMPED: �<BS ❑NO <br /> ❑CHRISTY BOX ❑STOVE P11IT\I S P C; .T;LL <br /> C'_T_j 0 N S CONCRETE PEDESTAL BY DRII,LER: OYES 1 <br /> 0 <br /> APPROXIMATE WELL DEPTH W&Q <br /> PROPOSED CONSTRUCTION/DRILLLINO METHOD: MUD ROTARY_D�,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: lA C, // jddd6&ifA <br /> TITLE: \�L6 TPN DATE: <br /> I � <br /> I Lr <br /> i <br /> -Q <br /> I <br /> i J <br /> I I M <br /> r .r"r til <br /> I - <br /> i i Y <br /> P JBI.lill Hc�� <br /> DEPARTMENT USE ONLY <br /> Application Accepted.By Datc '. , S-LTV Ares ' <br /> Grout Inspection By Date Z mp Inspected By Date <br /> Destmction Inspection By Date <br /> COMMENTS: <br /> PE SC AMOUNT CHECK_Vl RECEIVED DATE UEST 4 WELL M# <br /> CODES INFO RExmT C BY <br /> IbQ i 8 r MO $2 1� � 220 <br />