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WELL/PUMP PERMIT <br />�I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE.. STOCKTON CA 95202 (209)468-3420 <br /> JOB ADDRESS �/{I I�,� YYl I <br /> NON-REFUNDABLE IT EXPIRES 1 YEAR FROM DATE ISSUED - - <br /> ►+ PARCEL SIZEIAPN ' , 1 I ID <br /> OWNERNAME IVA <br /> ti/' -0rl ADDRESS e)C? ✓' ---- <br /> CITYILIP ��Y���D,,n/Y 7�,,y, PHONE n p�� <br /> CONTRACTOR 9/1 , rO/ RESS Y2 1 6�. I�Vim'- <br /> CITY(ZIP-1�V!tel �' ✓K ✓ PHONE i" `� ✓ C?Ll o <br /> GEOGRAPHICAL INF PMATION:COORDINATES X Y TOWNSHIP RANGE_SECTION <br /> k� TYPE OF WELL: af/NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL ❑OTHER <br /> l(�'' INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR R VAPOR EXTRACTION WELL N f - <br /> 1 ± TYPE OF PUMP: NEW ❑REPAIR H.P. DEPTH PUMP SET FT, FIRST WATER LEVEL /� <br /> iii 0 OUT-OF-SERVICE WELL 0 GEOTECHNICAL N ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE WELL CONSTRUCTION.,91'ErkrFICATION <br /> Cl INDU TRIAL OPEN BOTTOM WELL EXCAVATION DIA `i CONDUCTOR CASING DIA/ <br /> TIC PRIVATE ❑GRAVEL PACKISIZE WELL CASING TYPES-�2 WELL CASING D1A„_ � <br /> ❑PUBLIC/MUNICIPAL 0 DRIVEN GROUT SEAL DEPTH 520 SPECIFICATION S <br /> ❑IRRIGATIONfAG 24- HR "C) I C<=OTHER GROUT BRAND NAME - <br /> REQUESTS <br /> ❑MONITORING I^0 R A L- GROUT SEAL PUMPED: �Q/YES 10 <br /> ❑CHRISTY BOX ❑STOVE PIPE I N S P E CT I O N SIONCRETE PEDESTAL BY DRRLLF.R:{]d YES ❑NO <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTIONIDRILLING METHOLI:MUD ROTARY AIR ROTARY AUGER—CABLE_9�OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> i. <br /> SIGNED: <br /> — <br /> E:_ 0 DATE: <br /> Gu <br /> 42 <br /> � SO 6N <br /> � HE <br /> H . <br /> �V <br /> t---. DWARTMENT USE ONLY _ '-7 <br /> li Application Accepted By Dade v Area/ /may <br /> j Gram Inspection By ' ate um Inspected By-17 Da[c <br /> l <br /> Destmction Inspection By ate <br /> COMMENTS: <br /> PE SC AMOUNT (:2ffCKW RECEIVED DATE PERMITISERVICEREQUEST N WELL IDN <br /> CODES INFO REMITTED CASH BY <br /> �d 1 S73 <br /> FIil <br /> 366oa <br /> y3 gv jq v 2 3 0 <br /> F1 <br />