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>PPLICATION FOR WELL/PUMP PERMr <br /> SAA'JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 4683420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICampMla In TIIpDaalal <br /> APMICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDNR INSTALL THE WORK DESCRIBED.TNM AFPLICAT IS MADE N COMMIANCE WHIZ SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAWIN COUNTY PUBLIC HEALTH BEPnRcfS•ENVmONMEMK NEKTN OMagN. <br /> JOB <br /> ADDRNAMERAPNI OWNER 9 <br /> Mike,725 RAM0 S1Gclon Road ADDRESS 1605 <br /> Stockton PARCEL SIMAPNS, <br /> 1605 Parker, Ave, racy, Ca 7 <br /> CONTM TOR NnAf K PUMP rn. W/0 18681 ADDRESS 4500 E Fremont HD,504513 PHONE, 948-8817 <br /> PUB CONTRACTOR ADDRESS Stockton, 95215 LAOS PHONE0 <br /> TYPE OF MI111PUMP: ❑ NEW WELL ❑ PEMACEMEM WELL ❑ MONITORING WELL F ❑OTHER <br /> ❑ INSTALLATION ❑ WELL"STEM REPAIR ❑ CFOSStONNFCT REPAIR ❑ VAPOR EXTRACTION WELL P J <br /> ❑New❑R w' M.P. DEPTH PUMP SET-FT. FIRST WATER LEVEL O <br /> RYPE OF PUMm <br /> sem OOTG ❑ OVfOF-SERV CE WELL ❑ OEOPHYSICAL WELL P ❑ BOLBOMNO P <br /> qj DESTRUCTION: 5" f.a c;ng - n;g down 3' fill casing with bentonite, cap casing and fill to top <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> %4 <br /> r4 ; <br /> fliMAO�SoNj <br /> oeti <br /> fiY G U til —JAN 2,619% <br /> . .. <br /> L. . SFA JGAQUIN T'.,,•A r( ;... <br /> PUBLIC HEALTH SERI.CES <br /> BvVIRpNPdv.3TALY+EPLTH DP/ISIUN <br /> DEPARTMENT USE ONLY <br /> APellvelbn ApeaPled BY {` ��� De,e <br /> O.ovl Iwpmlbn BI One PvnP Imomaen BY Dele <br /> Orvunbn Irer,bn BY � `Z�/� <br /> Dne <br /> ACCOUNTING ONLY: AIDE FAC, <br /> PE CODES fEE INFO AMOUNT REMITTED CHECK 1CAam RECDVEO NY DATE R9NBT/aERNCF REOVFST NUMMI INVOICE <br /> C d <br /> 3 � e � <br /> Pub.Health Sam-Enviro.173(1/97) <br />