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Gk;3 S%S <br /> WELL/PUMP PERMIT <br /> SAN6QUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> ( ^ r <br /> 304E.WEBER AVE:.. STOCKTON CA 95202 (2119)468-3420 ry <br /> ®�iF ��SIL1 Y ►�., <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE I5SUFD 1 <br /> .r <br /> 1C1L�`ADDRESS_ . OS "0 Al. /)loL-L.Y OR/yE <br /> PARCEL S17FJAP����N��^_���� CLTY111P '}�/�GY //3 7(D <br /> OWNER NAr.tF Saw- ADDRESS AO S9 a N f7 aL�Y Df <br /> K' <br /> cmrrm G '71a- OZTPHONra-2�c,, ,� �'3,� 3 <br /> CONTRACTOR_ f ' ,( f- ION DRESS--Z 7/ <br /> CITY/LIP PHONE_�0/ - 7(y <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y_____TOWNSHIP_ RANGE._SECTION <br /> TYPE OF WELL: LI NEW WELL I3 REPLACEMENT WELL ❑ MONIItOR/NG WELL# _❑OTHER <br /> INSTALLATION: WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL k _ <br /> TYPE OF PUNIP 0 NFW �,jtEPAIR H.P. Ya DEPTH PUMPSET 17. ifPT. FIRST WATER LEVEL <br /> ❑OCT-OF-SERVICE WELL ❑GEOTECHNICAL M_ ❑SOIL BORING __ ❑DLSTRUCTIONi_—_____ <br /> INTENDED USE TYPE OF WELL CO INSTRUCTION SPECIFICATION <br /> *INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA -- CONDUCTOR CASING DIA- <br /> -0 DOMESTIC PRIVATE 13 GRAVEI.PACIUSILF WELL CASING TYPE WELL CASING DI.A-1-a _ <br /> O PUBLICAIUNICIPAL ❑DRWEN GROUT SEAL DEPTH __ SPECIFICATION-_-___ <br /> ❑IRRIGATION/AG OTHER GROU I BRAND NAME <br /> M MONITORING GROL7 SEAL-PUMPED: O YES O NO fhv <br /> ❑CHRIST Y BOX ❑STOVE PIPE CONCRM PEDFSTAL BY DRILLER: ❑YES Cl NO V <br /> APPROXIMATE WELL DEPTH �aVFf <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY_AIR RarARY—AUGER—CABLE OTHER 4 <br /> I HEREBY CERTIFY THAT I HA VE PREPARED THIS APPLICATION AND THAT THE!YORK WILL BE DONE IN ACCORDANCE.WITH SAN <br /> JOAQUIN COUNT/Y ORDIANCE.S,S'L'ATE I.AW S,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: <br /> TTTLE DATE: 7 o p' <br /> i <br /> -1— <br /> N m, r_ <br /> S;riVID <br /> DFPARTNIENT USE ONLY f J <br /> Application Accepted By Date <br /> Grout Inspection!y—--_--_ _—_—_Dam_----Pump Inspected By_ <br /> Destruction Inspecunn By Umc <br /> COMMENTS! <br /> 1'E Sc AMOUNT C 'CK RECEIVED DATE PFRMIT/SERVICF REQLL•ST p 4R'EI.L IDM <br /> CODES INFO RL-MITTED BY <br /> On 2- <br /> y I <br />