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i <br /> WELL/PUMP PERMIT <br /> SAN JOAQIAN COUNTY PUBLIC HEALTH SERVICES EN-V7RONMLNTAL HEALTl1 DIVISION PAYMENT 1 <br /> 304F..WFHERAVF., STOCKTONCA95202 (209)468-3420 RECEIVED <br /> I l(�p NON-RFFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> 10P ADDRESS ., , OCT 1 0 2000 <br /> PARCEL SIZFIAPN Crrymp _ _ SAN JOAOUINC;L)N Y <br /> -JOEL„ t <br /> OWNER NAMEEhVI <br /> --- - _-� pD ADDRESS [�,Jy <br /> .dr�Z+1JC.Lytld RO'JhiEN"4L f+EFIThI D'L1Sh:'J <br /> C'ITW71P� •• ,, _ _ y� PHONE, Cam) d� ,�{ 3yv_ <br /> CON'TRACTOR�,N 'A D�R3 ��Xj,� /�+� �lJ•. IXt7C l L/ --- -- <br /> CITY/7.1P 9530`! PI10NE 236 -aBly <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y_ TOWNSHIP, RANGE_SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL$1 _❑OTHER <br /> INSTALLATION: 91 ELL SYSTEM REPAIR ❑CROSS-CONNF_CT REPAIR ❑VAPOR EXTRACTION WELLS <br /> TYPE OF PUMP: Y151EW <br /> ❑REPAIR H.P. 1 DEPTH PUMP SET_.7�Fr. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL IY__ ❑SOIL BORING ❑DESTRUCTION: <br /> TENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN B0170M WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> 57�et1 r <br /> EST[C PRIVATE ❑GRAVEL PACKfSl7F; WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUTSEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG 24 HR N OT I C—'1_. OTHER GROUT BRAND NAME <br /> RE(at U ESTE Cl, <br /> 13 MONITORING E�,� ALL GROUT SEAL PUMPED: Q YES ❑NO ' <br /> ❑CHRISTY BOX ❑STOVE PIPs M S IP i=Ci*1 I iC­)i NCONCRETE PEUESTAt.BY URILLEA: DYES ❑NO <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTIONIDRIWNG METHOD: MUD ROTARY AIR ROTARY,AUGER CABLE_OTHER_ <br /> I HFRFBV CERTIFY THAT 1 HAVE PREPARED TINS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDIANCES,�STATE <br /> �LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED:9� t4k oA-- /�J� <br /> T TLE: --DATE: lyv --_ <br /> _ _ I <br /> i 1 <br /> I <br /> I � <br /> �/''� �?' <br /> DEPARTMENT USE ONLY ff ` <br /> Application Accepter By �;'1;' -8LL-.7 l..( 1 �P.1f. D <br /> Grout Inspection 5y Date Punta Inspected By _Date -Z'73-2� <br /> Destruction Inspection Dy __ ate <br /> fr•"o F M <br /> COMNIENTS. G�{�n �KTRiC K 8 Rx S q <br /> IL-1 i..t,p4j oC �/ <br /> PE SC AMOUNT HEC RECEIVED DATE. PERMrr/SEKVCIE REQUEST M WELL IDM <br /> _GOOFS INFO REMITTED CASH BY <br /> rb v� o <br />