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PF---- 704 E.WEBER AVE.. STOCKTON CA 95:03—('091168]420 <br /> CrW\i' <br /> NON-REFUNDABLE PERMIT EXP SS I YEAR FROM TE 1 UED <br /> JOB ADDRESS / S • -..(C 'CR <br /> PARCELSIZ&APN CI"TY21P Zr4c_ �.tA✓� �{'�J (�C� <br /> OWNER NA//M` C 5�V'•��l ADDRESS <br /> RB' L. <br /> CY/L ./' E�� PHONE <br /> CONTRACTOR ��(,sC .(, AC^DDRFSS c) '�F�2 /!/�'l 4`C�. /[l./♦ F K <br /> )NT- <br /> GEOGRAPHICAL <br /> NEGEOGRAPHICAL INFORMATION: COORDINATES X Y_TOWNSHIP_ RANGE_SECTION <br /> TYPEOFWELL: Cl NEWWELL ❑ REPLACEMENTWELL 0 MONITORING WELL* 13 OTHER <br /> INSTALLATION: 6WELLSYSTEMREPAIR ❑CROSS-CONNECTREPAIR O VAP,,ORRE..X�TTRACION WELL* G <br /> TYPE OF PUMP: Cl / <br /> NEW <br /> REPAIR H.P. DEPTH PUMP SET SFr. FIRST WATER LEVEL /OS <br /> Cl OUT-OF-SERVICE WELL 13 GEOTECHNICAL N OSOILBORING ODESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> O INDUSTRIAL E3 OPEN BOTTOM WELLEXCAVATIONDiA_ CONDUCTORCASINGDIA_ <br /> XDOMESTIC PRIVATE O GRAVEL PACK/SIZE— WELL CASING TYPE WELL CASING DIA <br /> O PUBLICIMUNICIPAL E3 DRIVEN GROUTSEALDEPTH SPECIFICATION <br /> ❑HOUGATION/AG OTHER GROUT BRAND NAME (P <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES 0 NO <br /> 0 CHRISTY BOX O STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES 0 NO <br /> �/'Y T <br /> APPROXIMATE WELL DEPTH ' tkpn <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY_AIR ROTARY_AUGER_CABLE_OTHER_--{T' I. <br /> I HEREBY CERTIFY THAT 7 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORIW NC�lyf[R'Sy"1 <br /> JOAQUIN COUNTY ORDIANCES,STATE S,AN ULM AND REGULATIONS OF SAN JOAQUIN COUNTY. 1YF'HCE`�,IE <br /> SIGNFJ): 20G3 �; <br /> TTIT.E: DATE: f/ 'OONTM.,i <br /> TT <br /> N 1� <br /> 1 <br /> DEPARTMENT USE ONLY <br /> A,I., .Accepts By <br />