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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE„ STOCKTON CA 95202 (209)468-342D <br /> �. <br /> '�'•'{'����� -REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDR15 ` <br /> PARCEL SIZEIAPN 1 CITYIZIP ✓�•• <br /> OWNER NAME I!L �k-CL ADDRESS <br /> CiTY/ZIP ~w ✓`-�' PHONE <br /> CONTRACTOR4k. L- ADDRESS <br /> CIT'YMP `��ioc�(c�/�3�� `"L sSa.If' <br /> PHONE `f Ire.� <br /> GEOGRAPHICALINFOPMATION: COORDINATES X_ Y_TOWNSHIP RANGE_SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL 0 MONITORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CR�O/S/ CONNECT REPAIR ❑VAPOR EXTRACTION WELL# - <br /> TYPE OF PUMP: KNEW ❑REPAIR H.P. "/'LDEPTH PUMP SET 7 FP. FIRST WATER LEVEL Z c' <br /> F ❑OUT,OFSERVICE WELL ❑GEOTECHNICAL# ❑SOH.BORING ❑DESTRUCTION: <br /> k <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA- <br /> (DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL [3 DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRI(Gk ION/AG OTHER GROUT BRAND NAME <br /> I LLL--- <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO- <br /> ❑CHRISTY BOX ❑STOVE PIPECONCRETE PEDESTAL BY DRILLER: ❑YES 13 No <br /> P/I <br />'i APPROXIMATE WELLDEPTH C <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY_AIR ROTARY AUGER CABLE______OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDIANCES,ST LAW ND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, <br /> SIGNED: <br /> TITLE: �� .DATE: <br /> C <br /> ti <br /> 0 i <br /> 5F <br /> C,p9 lir p�p�AT,(R�y7ry�T USE N Y f/ <br /> Applicetion,Accepted By L �/`�"— ale �" Area e�dyII <br /> Grout Inspection By Dale Pump Inspected <br /> Destruction Inspection ByT - .Date <br /> III COMMENTS: <br /> 444 PE SC AMOUNTHECK# RECEIVED DATE PERMITISERVICE REQUEST 0 WELL ID# <br /> CDES WO�W � R8M[TI"ED a63) 104 <br /> >� s2 002--5-302 <br /> E <br />