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WELL/PUMP PERMIT <br /> i <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SLRVICES ENVIRONMENTAL HEALTH DIVISION PAYMENT <br /> 304 F_WEBER AVE.. STOCKTONCA95202 (209)468-3420 RECEIVED <br /> f NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 1 &.-t .", OCT j 0 2000 <br /> PARCEL SIZrJAPN CITYrLlp SAN JOAQUIN COUN"Y <br /> `� �AJ _ u S <br /> OWNER NAMEIYA ADDRESS �� .1C.�'4�D FNVISC'161EP!'.4LFF.AITfID't1SIC`I <br /> CrrY/ZIP o��o�.�An <br /> /_� <br /> CoNTRACTOR�,J �� LrJLQQiJK 1�' If d0-AD R SSS ,e Oe/ _ [•U ✓�I L - -— <br /> cITY/LfP .Ia. _1530 PIIONE '236 -a 814 <br /> GEOGRAPHICAL INFORMATION: COORDINATES X__ Y - TOWNSHIP____ RANGE —SECTION. <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL a _❑OTHER <br /> INSTALLATION: ELL SYSTFM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL S <br /> TYPE OF PIMP: gyvcW ❑REPAIR HP DEPTFI PUMP SET 3p-____17T. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL P ❑SOIL DORING ❑DESTRUCTION:_ _ <br /> INTENDED US TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL. ❑OPEN BOTTOM WELL EXCAVATION DIA_- CONDUCTORCASINGDIA <br /> 17•GpMETIC PRIVATE D(IRA VEL YACKISI7.E WLLL CASING TYPE WELL CASING DL4�_ <br /> !❑PUBL::/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG 24 HR N QT I C;i_. OTTIER GROUT BRAND NAME <br /> REG?UFSTEL` <br /> ❑MONITORING FO:� ALL GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPIT NS�P S-C,"1"R C)N!=? CONCRETE PEDESL.TABY DRILLER: ❑YES 13 NO <br /> APPROXIMATE WELL DEPTH '`TJ� — <br /> PROPOSED CONSTRUCTION/DRILLIN(,.MF.THOD: MUD ROTARY_AIR R61'ARY_AuciER`CABLE_OTHER_ <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED TIDS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY <br /> O�JRDIANCES,�STATE <br /> �LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> ---- <br /> TITLE: DATE: 1"100 <br /> II <br /> EN— _T_ I <br /> DEPARTMEN7 USE ONLY <br /> -D <br /> Application Accepted B � D e <br /> PP P Y --— <br /> Grout Inspection By Date Punta Inspected By <br /> (LLDestmetion Inspection By - ate <br /> COMbiEN rs: <br /> ?3 / 1�'3'7°°a F� X #Lylrx s µ <br /> PE SC AMOUNT HEC RECEIVED DATE. PERMIT/SE E REQUEST p WELL IDM <br /> CODES INFO REMITTED CASH BY <br /> I <br />