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\ � WELL,PUMP PERIMIT � / <br /> SAN JOAQUIN L4TIVTY PUBLIC'HEALTH SERVICES ENViRONMENTA wkALTH DIVISION <br /> .04 E.WEBER.\VE.. STOCKTON CA 15202 2091;68.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DA'Z'E I$SIJED. � I - <br /> .'�.1s'"C <br /> JOB ADDRESS �, 5..._r^/ln rt n AI`� n t10 (� <br /> i PARCEL SMAPN S CTTYrLIP ,--)LC C k 4.1 <br /> CA43 In 1* <br /> OWNER NAME (-I„�_y.�[� A ADDRESS i, o- 60Y );?11-4G <br /> CTTYlZIP C fn -k 1-a n GS c ? PHONE 2 CR - q(a4C f!1!�!- <br /> CONTRACTOR J 1 W CZM-,O l ADDRESS 11356 Mon T e r-7a rk ► tat r? _ <br /> Cmrrzr 1( y\p l `,r d cULL q S 74:L NE Cr l(G- A,S3-AQZ_"5 <br /> GEOGRAMCAL INFORMATION: COORDINATES X_ Y TOWNSIflr RANGE SECTION ' <br /> TYPE OF WELL: O NEW WELL 0 RFRACEMM WELL 0 MONITORING WELL M 0 OTHER 1 <br /> i <br /> INSTALLATION: O WELL SYSTEM REPAIR O CROSS-CONNECT REPAIR O VAPOR EXTRACTION WELL# i <br /> TYPE OF PUMP: ❑ NEW 0 REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> 0 OUT-OE SERVICE WELL O GEOTECHMCAL k ❑SOI.BORING )(DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL 0 OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE 0 GRAVEL.PACK/SUE- WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLICIMUNICIPAL 0 DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG 2-4 HR N OT'1(=gLNER GROUT BRAND NAME <br /> 0 MOWTORING R E Q U E S TE L3ROUT SEAL PUMPED: 0 YES ONO i <br /> F=*Qr ALL <br /> O CHRISTY BOX 0 STOVE PIPE l N S p E CTi p N 9NCRETE PEDESTAL BY DRILLER: 0 YES 0 NO <br /> APPROXIMATE WELL DEPTH <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: DATE: <br /> I I I 1 I I i I I <br /> • i I I i i ! I I 1 I I i I � 1 i � 1 i i I I <br /> I <br /> ! jI CA C I j <br /> i I I I i i <br /> i <br />