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WELL/PUMP,. KNIT r— S JN`JOAQUIN COUNTY PUBLIC HEALTH SFRVICE,�eNVIRONMENTAL HEALTH DIVISION 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 V3NON-REFUNDABLE PERMIT/EXPIRES I YEAR FROM hSSUtHN JOB AO ✓ /T /c� L Iva V.el PAR L :E/APN `�S C1TYflIP ` OWNER NAME_jr J �ADDRESS I &r CITY/ZIPO'NNE�E azz CONTRACTORS ADDRESS_( CITY/LIP__ 13Y�-/V��'S�1PHONE GEOGRAPHICAL INFORMATION: COORDINATES X_ Y_TOWNSHIP RANGE_SECTION TYPE OF WELL:,X NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER INSTALLATION: 0 WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# TYPE OF PUMP: &,�kEW ❑REPAIR H.P. DEPTH PUMP SET �yyr FT. FIRST WATER LEVEL ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING 13 DESTRUCTION: INTENDED TYPE OF WELL NST1111'ION SPECIFICATION f ❑INDUSTRIAL 13 OPEN BOTTOM WELL EXCAVATION DIA IZ� CONDUCTOR CASING DIA u OOMEST[C PRIVATE RAVEL PACKISIZE WELL CASING TYPE WELL CASING DIA ❑PUBL]CIMUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATIONS_ ❑IRRIGATION/AG 2-4, "R N CD-Fl C F THER GROUT BRAND NAME , ❑MONITORING R E C?U E ST E ED GROUT SEAL PUMPED: s ❑NO F FOCI ALL 1 ❑CHRISTY BOX ❑STOVE PIPE iN s P E CT I Q N SCONCRETE PEDESTAL BY DRILLER: ❑YFS APPROXIMATE WELL DEPTH _ : 1--� t - PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY-/VAIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN CO AIILC ,ST 1 ND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. E SIGNED: �y TITLE: DATE: ! / I PA AI Rl ew ItALU-mv m isE i PrP �- DEPARTMENT USE ONLY I Application Accepted By C ! Date 00 Area v 1 0 - 4 y Grout Inspection By Date j6—�d qump Inspected By Gam✓ Date/,_J 9—Q Destruction Inspection By pate i E COMMENTS: SC AMOUNT HECK# RECEIVED DATE PERMIT/SERVICE REQUEST# WELL IDA INFO REmrrrED BY 67 N to L6 �- .;z