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G,/C'3S/rS <br /> WELL/PUMP PERMIT <br /> SAN QUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> a I%, r.i 304E.WEBERAVE.. SIOCKTONCA95202 (209)465-7420 -`I <br /> VA <br /> ��\'�{ �1�� <br /> NON <br /> --REFUKDABLE PERMITEXXFIRFS I MR FROM DATE ISSUED WEt v <br /> J(JCAODRFSS 20SO� N� &LI-Y , , eI'yE L VVV <br /> PARCEL simAPN CTTY14P /iY/RGPY 5 S'3 7/- <br /> OWNER NAME-ot�kFLJ SuFrgr�n_nDRFssOS-oa N NaLG .�IC <br /> IF "s"` <br /> COY(IIP ZT 6'3S— 3 2 ri7 <br /> G PIIDNP G /1 <br /> CONTRACTOR E ISG ION F DRESS IS ( Of�IIGA/V CICN1-4 S _ <br /> CPTYlLIp PHONE d 7,7- � / <br /> 6L- o ' <br /> /- <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y__TOWNSHIP_ RANGE_SECTION <br /> TYPEOFWELL: 0 NEWWELI, O REPLACEMENI'WELL 0 MONITORING WELL 4--0 OTHER <br /> INSTALLATION: )()lELL SYSTEM REPAIR OCROSS-00NNECTREP.AIR O VAPOR EXTRACTION WELL» <br /> ��..(z�Ii <br /> TYPEOFPUMP: CINEW kEPAIR H.P. DEPTH PUMPSEI'¢�FT. FIRST WATER LEVEL <br /> 0 OUT-OF-SERVICE WELL O GEOTECIEVICAL M O SOIL BORING___ O DFSTRUCUON: <br /> INTENDED USE TYPE.OF WELL CONSTRUCTION SPRCIFI CATION <br /> ViNDUSTRIAL 0OPEN BOTTOM WELL EXCAVATION DIA—,___ CONDUCfORCASINGDIA__ <br /> // <br /> ODOMESTIC PRIVATE O � <br /> GRAVEL PACKfSIG _ WELL CASING TYPE WELL CASING DIA '�04�29 <br /> O PUBLICMUNICIPAL 0DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> — <br /> 13 IRRIGATION/AG OTHER GROUT BRAND NAME <br /> 0 MONITORING GROUT SEAL PUMPED: 0 YES ONO Q <br /> O CHRISTY BOX O STOVE PIPPE/ ^� 1 CONCRLTE PEDESTAL BY DRILLER: OYES 0 NO <br /> APPROXIMATE <br /> PKOPOSEDCONSTRUCTIONIDRdLMMETHOD: MUD ROTARY_AIR ROTARY_AUGER _CABLE_OO{ER__ <br /> I HEREBY CERTIFY THAT INA VE PREPA RED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE.WITH SAN <br /> JOAQUIN COUNTY ORUTANCES.STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED <br /> Tm E. __DATE.: 7 n d <br /> AAA <br /> i �ZI <br /> IR I <br /> I <br /> t— <br /> y� T <br /> DEPARTMENT USE ONLY ry <br /> APPlicaaon Acwpuzl BY r-��" Dale_3-7_n�Le�29'� z <br /> Gaut In pcction UY Da¢ FLmp lnzpectd BY-f+^��L= <br /> Dcssmcuun lnzpccuon By <br /> COMMENTS: <br /> PE SC AMOUNT 'CK RECEIVED DATE PERMlTI5GlV10E REQUGSTs WELL IDP <br /> CODES INFO RGMII"IED BY <br /> 3 s0 1n�+' <br />