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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 <br /> AUG 1 8 2000 <br /> p,T•- NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED j <br /> i <br /> ,,,� `� S ��`/ ! '� SAN JOAQUIN COUNTY <br /> JOB ADDRESS :ZAA-/ PUB IG I IE"LTI I SERY16ES <br /> PARCEL SIZEJAPN CITYMP --7 I / EMMONMENTAL HEALTH DNISION '.. <br /> OWNERNAME fIL.VIq�/"2 ff),�/19lJ/yKDDRESS / 5 % /.//Vit/F /L./� / /_. � 7>% <br /> CITY/ZIP PHONE <br /> CONTRACTOR rt)L,(iU1l/1c`1: D01414115, ADDRESS 3O0 S ILII 641Z <br /> crrr/ziP 10el-OCK 01 %Y,d'V PHONE 6-& 7-79.5'2_ <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y_ TOWNSHIP_ RANGE_ SECTION <br /> TYPE OF WELL:CCI NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> i <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 /> i <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE SOF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑.OPEN BOTTOM WELL EXCAVATION DIA_(O /A/ CONDUCTOR CASING DIA_ <br /> __!D4-DOMESTIC PRIVATE GRAVEL PACK/SIZEd_4 WELL CASING TYPE T V L 'WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH O/" SPECIFICATIONGA^l�� GI/Fa <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME k r=N /7-.,o jolyl <br /> ❑MONITORING GROUT SEAL PUMPED: ;PFYES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES 12r-NO <br /> APPROXIMATE WELL DEPTH —2 <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY_AUGER_CABLE_ OTHER V�1 <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY OR) IANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> ....SIGNER:::. <br /> I <br /> ` TITLE: '- / - DATE: <br /> 5 <br /> 41 <br /> 1 <br /> r <br /> DEPARTMENT USE ONLY <br /> y [y /_ <br /> Application Accepted By I r 1 Date 75 —�J :Al)A.a lb 99 <br /> Grout Inspection By Date Pump Inspected By Date <br /> Destruction Inspection By Date <br /> COMMENTS: <br /> PE SC AMOUNT EC RECEIVED DATE PERMIT/SERVICE REQUEST# WELLID# <br /> CODES INFO REMITTED CASH BY <br />