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WELL/PUMP PERMIT ` PAYMENT " SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION RECEIVED `*'-r'a^ 304 E.WEBER AVE., STOCKTON CA 95202 ' (209)468-3410 nnR NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED S E F �UUU ,60,�, _,�. J r� ry TY JOB ADDRESS !"{ PUBLIC BEAR SEuuICES 5 � G PARCEL SIZE/APN lf CITYCZIP L/KA i JSSrs ADDRESS- OWNER NAME ` �1 S "' PHONE / �3 - 70 CITY/ZIP CONTRACTOR ADDRESS �J CITYIZIP Qa PHONE / v GEOGRAPHICAL INFORMATION. COORDINATES X Y TOWNSHIP RANGE SECTION NEW WELL ❑ REPLACEMENT WELL ❑ MONITbRING WELL# ❑OTHER TYPE OF WELL:X INSTALLATION: ,WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# TYPE OF PUMP: 13 NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICppA��TION ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIAD.:_ CONDUCTOR CASING DIA ,._ "p DOMESTIC PRIVATE .GRAVEL PACKISIZE WELL CASING TYPE�y� WELL CASING DIA PUBLICIMUNICIPAL ❑DRIVEN GROUT SEAL DEPTH2_a2 LLS,,PECIFICATION ❑IRRIGATION/AG 24 H dTHER GROUT BRAND NAME��r�� R "(D-FICC E ❑MONITORING R E C�U C S-rE r) GROUT SEAL PUMPED: RYES ❑NO i ❑CHRISTY BOX ❑STOVE PIPE C..7 R ALL CONCRETE PEDESTAL BY DRILLER: YES ❑NO � lNSF�E�%�`lONS APPROXIMATE WELL DEPTH PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR 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 COUNTY ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. J SIGNED: G"� TITLE: pL(//t SII- DATE: M O R DEPARTMENT USE ONLY. Application Accepted By -777 , Date 9 � .0`�� Area Grout Inspection By Date ri ump Inspected By Date 415 Destruction Inspection By. Datc COMMENTS: PE SC AMOUNT HECK RECEIVED DATE PERMITISERVICE REQUEST# WELL ID# CODES INFO REMITTED H BY