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` •� WELL/PUMP PERMIT PAYMENT <br /> I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION RECEIVED <br /> 304 E.WEBER AVE.. STOCKTON CA 95202 (209)468-3420 <br /> �qq r� n <br /> NON-RE FUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ` {2 G 2000 <br /> `r JOB ADDRESS : ._ �� {�; 4 y ..i � <br /> n _ _ <br /> E:.16LIC HEALTH SERVICES <br /> PARCEL 5iZE/APN Z-l�'� 1 �1.J' ^CrrYFLIP r- Etmgf];:{:CENTAL HEALTH 01VISION <br /> OWNER NAME��{fl , l A` •` <br /> Z7L L'.,.1 I ��JADDRESS ��. ' �~ f t � <br /> CITY/Zip!.!�f d(_L�_1 -01 CX)-i3 c- PHONE <br /> CONTRACTOR it r�f 1 1�Jrt ��I.4�(�,f f� . ADDRESS <br /> CITY= - i � t ` �l I P [ONE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: 41 <br /> EW D REPAIR H.P. DEPTH PUMP SETA?e FT, FIRST WATER LEVEL <br /> ❑OUT WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> a{ INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> k 1 sJ <br /> 4 0 INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIffiz--AV �rCONDUCTOR CASING DIA <br /> I ❑DOMESTIC PRIVATE RAVEL PACK/SIZE WELL CASING TYPe_s� WELL CASING DIA <br /> ' ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH Q SPECIFICATION <br /> IRRIGATION/AG OTHER GROUT BRAND NAME <br /> { , ❑MONITORING 2 4 �`i+R N GROUT SEAL PUMPED: ❑YES ❑NO '� <br /> ❑CHRISTY BOX ❑STOVE PIPE U ES`t`� CONCRETE PEDESTAL BY DRILL R: ❑YES 0 NO <br /> APPROXIMATE WELL DEPTH ,04 <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTTiFRe&Ve <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> ' + JOAQUIN COUNTY 900,1ANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. Q <br /> -� <br /> TITLE: <br /> 9.10 wLn <br /> CN <br /> aW$ <br /> CL <br /> F E �. <br />