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WELLIPUMP RERMIT'�= <br /> ltQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE., STOCKTON CA 45202 (209)468-3420 <br /> ���j 99 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSU� <br /> E JOB AL ESS ��.. <br /> I� <br /> PARCEL SIZE/APN CITY/ZIP CIL}]Y <br /> OWNER NAME ADDRESS <br /> CITY/ZIP / C&Z?z / Y PHONE w <br /> CONTRACTOR C&kAdEW I Rga4X DRESS <br /> CITYIZIP-702mrp 641 PHONE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: 16- NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL it ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: (3 NEW ❑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 SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA,;?2/,� CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE GRAVEL PACK/SIZEJ6. 2 WELL CASING TYPE ✓/Ziet_ WELL CASING DIA _ <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH ;rC <br /> SPECIFICATIONS___ <br /> DZ,IRRIGAT[ONlAG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: QfYES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑ YES. CKNO <br /> APPROXIMATE WELL DEPTH��f <br /> PROPOSED CONSTRUCTIOWDRILLING METHOD: MUD ROTARIC-,._AIR ROTARY AUGER CABLE OTHER <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,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: <br /> TITLE: DATE: <br /> C <br /> Aj <br /> r O <br /> C <br /> CI1US <br /> ire <br /> 440 <br /> i <br /> k <br /> _. <br /> DE.P, T-NIEN -UWONL-Y <br /> Application AcceptedBy 6 I Arca <br /> Date <br /> ��- <br /> E Grout Inspectio etp Inspected By Date <br /> f Destruction Inspection By Date <br /> COMMENTS' <br /> PE SC AMOUNT RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# <br /> CODES INFO REMITTED CASH Y <br />