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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUeLtC HEALTH SERVICE5 ENVIRONMENTAL HEALTH D <br /> WELL <br /> II <br /> , -304 F.WEBER AVE., STOCKTON CA 95202 (209)a633a20'7 r NON-RiFUND�BLE PERMIT EXPIRES i YEAR FR011 DATE ISSUED / <br /> ] <br /> !OB ADDRESS � <br /> r <br /> {E <br /> I J <br /> PARCELSIZFJAPN <br /> �� CITY2IP C <br /> OWNER NAME\ J <br /> ADDRESS r <br /> Fi CITY12,H1 <br /> CITYfLI ' v 1 ( / PHONE <br /> I <br /> GEOGRAPHICALINFORMATION: COORDINATES X— F'_ TOWNSHIP_____ RANGE_SECTION i <br /> it <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMEN7 WELL 0 MONITORING WELL# <br /> ❑OTHER � <br /> INSTALLATION: 0 WELL SYSTEM REPAIR ❑CROSS-CON,FCT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OFPU+IIP: Q NEW ❑REPAIR H.P. DEPTH PUNIPSET FT. F{RST WATER LEVEL <br /> 11 <br /> OUT-Or-SERVICE WELL 0 GEOTECHNICAL# <br /> INTENDED U ❑SOIL BORING �I DESTRUCTION: /�- S I'�Y! <br /> SF. i <br /> TYPE.OF IVELL CONSTKUCT{OiV SPP:C{FICATION <br /> ❑INDUSTRIAL ❑OPEN B07'P01A WELL EXCAVATION DIA c -! -?CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACRlSIZE WELL CASING TYPE S d"!-4 WELL CASING DIA C-- <br /> 0 PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SZ�� r ? �— <br /> r SPECIFICATION <br /> ❑IRRIGATSONlAG2 tea- l-�ft N CDT I,�F�R GROUT BRAND NAME <br /> ❑MONITORING P-i E Q V E S-1-E-:LD 1 <br /> FC� GROUT SEAL PUMPED: ❑YES ❑NO 1 <br /> ❑CHRISTY BOX ❑STOVE PIPE I M S IDE C�-I I Ca TRETE PEDESTAL BY DRILLER: ❑YES .ONO <br /> APPROXIMATE WELLDEPTH <br /> PROPOSED CONS"CRUCTIONIDRILLING METHOD: NIUD ROTARY AIR ROTARY_AUGER—CABLE_ OTHER-_ <br /> I IIERL13Y CERTIFY THAT 114AVIL PREPARCD THIS APPLICATION AND THAT THE WORE WILL III,,DONE IN ACCORDANCE'WITH SAN]pAQUIiY COUNTY OEtD IANC"ES/7S.TATE LAN'$,AND RULRS AND REG1Jj)f%TIONS OF SAN JOAQUIN COUNTY / LL <br /> A�1erJ[ C.J C irle3 [cSC�L 1,J:�I �J.`ih L Sts c'L� CfinC <br /> SIGNED: <br /> TITLE: DATE:__ /.�I--71"C:7 <br /> _ � I <br /> I -f <br /> { <br /> i <br /> t I <br /> I � � <br /> Fi - <br /> - xFj <br /> el <br /> i l <br /> Application <br /> Groin Inspection By Date Pump Inspected By r�l;N�Y �I1 <br /> F—'4� Date <br /> Dcsirnction Inspection By pL+YSi.iC�It l+;lii.f,i. ,�VV`.:Il1N <br /> COMMENTS: <br /> P's <br /> PE SC AMOUNT CHECKW RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# <br /> CODES - rrI��NFO REi11TT D By J <br /> �� W �0�� TaU a�. yi 11w S� DC7 1! f 0 <br />