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rAx0 0 <br /> zss-��s! <br /> WELL/PUMP PERMIT RECEIVED <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 r 1 <br /> .. , NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED AUG L Z00o <br /> J 5 / % S. �A l/1 /� SAN JOAQUIN COUNTY <br /> JOB ADDRESS ,A / PNBLIO I IEAHI I SERUIBES— <br /> PARCEL SIZE/APN CITY/ZIP-TIC14 r l A ENVIRONMENTAL HEALTH DIVISION <br /> OWNER NAME flZ-V/R'�C Z Ffl,Cfh'I .//V(DDRESs /--7 J 7 Al AlAa A:/) ! /..r/r_�/ 9-f.J 7� <br /> CITYIZIP PHONE <br /> CONTRACTOR r1)L_U11TT17k f)OWW(_ ADDRESS <br /> CrrY/ZIP /93 PHONE � <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y_ TOWNSHIP_ RANGE_ SECTION <br /> TYPE OF WELL:,C7 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 /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPEbF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑.OPEN BOTTOM ���/ WELL EXCAVATION DIA_/Q IA/ CONDUCTOR CASING DIA__ <br /> DOMESTIC PRIVATE �rGRAVEL PACK/SIZE!! W0 WELL CASING TYPE 11 VL 'WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH?DO t i SPECIFICATION(-Pa7t 4CIRI <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME oV(1(1�i'/(/ 17 j'./J/aly(12 <br /> i <br /> ❑MONITORING GROUT SEAL PUMPED: ;E. YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE / CONCRETE PEDESTAL BY DRILLER: ❑YES 021-NO <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTION/DRILLING 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 ORPIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> .....SIGNED:.I J r / <br /> . .TITLE: ._ . - DATE: 'f IO <br /> i n � <br /> DEPARTMENT USE ONLY <br /> i Application Accepted By I r 1 - '� Dare ' '-� )Area <br /> IDate <br /> Grout Inspection By Date Pump Inspected By <br /> Destruction Inspection By Date <br /> COMMENTS: <br /> PE SC7REMITTED <br /> 7CA <br /> RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# <br /> CODES INFO BY <br /> b d �2� S►�� 5� W 2 0 '75358 <br />