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!J <br /> WELL/PUMPPERMI_ f I <br />� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTA HEALTH DIVISIooco <br /> 304E.WEBERAVE STOCKTONCA95202- (209)468-3420 N N-REFUNDABLEPERMITEXPI ES 1 YEAR FROM DATE ISSUEDi\ )) <br /> [1018ADDRESS _ <br /> PARCEL SIZE/AP/NN n CITY/ZIP c�I��,,,vV� (/1 <br /> OWNERNAME 1, �1/ ` GIL�.Il]7/YIft_lUDRESS ✓v/II �- <br /> CITY/ZIP <br /> 1119-PHONE <br /> ADDRESS 5-- L,CONTRACTOR /DnS CITY/ZIP !-U PHONE 2Q <br /> I <br /> O — <br /> GEOGRAPHICAL <br /> `INFORMATION: COORDINATES X_ Y_ TOWNSHIP_ RANGE_ SECTION <br /> TYPE OF WELL: ffi NEW WELL 11REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: '❑`WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: r / ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER.LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFIC�ATTI N �� <br /> ❑INDUSTRIAL ❑OPEN BOTTOM' WELL EXCAVATION DIA_I_iL CONDU ORA 1 DPA Fes" <br /> �/ <br /> . -❑DOMESTIC PRIVATE GRAVEL PACK/SIZE WELL CASING TYPE PVC - WELL CASING D�"IA�_�,� <br /> )/'UBLIC/MUNICIPAL El DRIVEN GROUTSEALDEPTHa QG'(, SPECIFIICATIOtvfj+�dlTW)aF4_ <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME/ U/ <br /> ❑MONITORING GROUT SEAL PUMPED: N6ES 11 NO <br /> CICHRISTY BOX ❑STOVE PIPE �7 CONCRETE PEDESTAL BY DRILLER: ❑YES � NO <br /> APPROXIMATE WELL DEPTH o��{177 <br /> !} + <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY__?K,AIR ROTARY AUGER—CABLE OTHER. !P <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,A D RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> I <br /> SIGNED: <br /> TITLE:_ ... DATE: <br /> f <br /> la <br /> DEPARTMENT USE ONLY / <br /> pplica[ion Accepted BY Dote <br /> iroI Inspection By Dal -/3-2o/'Pump Inspected By <br /> Destruction Inspection y We <br /> COMMENTS: 11.� A9T oTld'IA <br /> M pI ✓ .c,/Y�9TGkwMT <br /> I#2_ S R090-W& J /-20oa- �>8 w4a 0 Au ° vest R/NnV-D <br /> ENS PL <br /> PE: SC AMOUNT CH K# RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# llf{ <br /> CODES INFO REMITTED A BY <br /> 132a lea L a a a`l i sR o oa-3 ? � <br /> 1inq lb5 ooa3 736 <br />