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WELLTUMP PERMIT <br /> SAN JOAQUIN-Jli:rTY PUBLIC I4EALTH SERVICES ENVIRONMEN.. HEALT7F V IV,S <br />--- I 304 E.WEBER AVE., STOCKTON CA 95702 (2D9)-63-342011, <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IOBADDRESS _- <br /> r <br /> PARCEL SIZEIAPN CITYI"LIP - edfI y _ <br /> OWNER NAME ADDRESS <br /> CITYfZIP— ngi- 4 PHONE <br /> CONTRACTO P i IC ADDRI?S� Fie!J4 f �-le"ft' F PO /Lx <br /> CITYIZIP 2 Q PHONE -2 0 9 �F�.a <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y TOWNSHIP— RANGE SECTION <br /> TYPE OF\YELL: ❑ NEW SVELL ❑ REPLACEMENT WELL 11 MONITORING\YELL.4 ❑O-fHER 1 <br /> INSTALLATION: N WELL SYSTE,\I REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL#-- <br /> T1 PE OF PUMP: )SNEW ❑REPAIR H.P. <br /> z✓ DEPTH PUNIP SET 657 Fr. FIRST WATER LEVEL I0 <br /> ❑OUT-OF-SERVICE WELL D GEOTECHNICAL# 0 SOIL BORING ❑DESTRUCTION: <br /> INTENDEDUSE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL 0 OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> DOMESTIC PRIVATE ❑GRAVEL PACKIS1ZE_ WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLIGMUNICIPAL ❑DRIVFN GROUT SEAL[DEPTH SPECIFICATION � <br /> I <br /> ❑IRRIGATION/AG 24 H F� "C_)_F1C;E OTHER GROUT BRAND NAME <br /> ❑MONITORING R E Q U E__F E tD GROUT SEAL.PUMPED: ❑YES ❑NO <br /> FCaE; �Li_ <br /> ❑CHRISTY BOX ❑STOVE PIPE /� c.� E C-�—�G CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXI', ` <br /> IATE WELL DEPTH !D l� <br /> i <br /> PROPOSED CONSTRUCCIO4;DRILLING METHOD: NIUD ROTARY______AIR ROTARY AUGER_CABLE______OTHER 1 <br />` 1 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 /> F'AYFN-1 <br /> $rGNED: /1 d(fl9 �1i�a� R .CE41/]t1Lf'1 <br /> TITLE: -, �/�!/�e'It� T DATE: <br /> Ni 311 dtV L.- ! <br /> L/j <br /> t I <br /> I <br /> I ! I <br /> i h l / IN IN <br /> I ! <br /> 7, <br /> I <br /> I I I I I I <br /> I I I I I I <br /> I I <br /> I I I ! <br /> I i <br /> I <br /> r 'r I I <br /> I I I I I I I ! I I I ! I <br /> 5. t <br /> DEPARTNIJENT USE ONLY <br /> Application Accepted By zK <br /> Oahe ~Shy <br /> Groat Inspection By Date Pump <br /> Dcstmction Inspection By Date <br /> CON4MEN'TSf 'v <br /> SISI dD O "i;ti RtnUfiS_ <br /> r IR�,II,a,,�•� <br /> PE SC AMOUNT HECK#/ RECEIVED DATE PERb1iTISERVICE REQUEST 0 WELLID# <br /> CODES INFO RENIIMcD CASH BY <br /> 7SI <br />