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'Now WELL/PUMP PERMI',,,/ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DMSION <br /> 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 <br /> NON- NDA I E T EXPIRES 1 YEAR FROM DATE ISSUED 'rl <br /> JOB ADDRESS �` LP <br /> PARCEL SIZEIAPN O CITY/; <br /> OWNER NAME < t ADDRESS � r✓L e <br /> CITY/ZIP PHONE <br /> CONTRACTOR c/�� ADDRESS ��7 �_ •/� � <br /> CITY/LIP _NAL <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y_ TOWNSHIP_ RANGE_ SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW 'KREPAH2 H.P. DEPTH PUMP SET_j4a__FI. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <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 ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTION/DRILLING 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 /> JOAQUIN7RDIANICES,STA AWS, RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: .c� <br /> TITLE: JVYO S DATE: <br /> S J N IN ,I. <br /> b <br /> - EPARTbIENT USE ONLY -- <br /> Application Accepted By Date -Area Z 1 Z L 6/ <br /> Grout Inspection By Date Pump Inspected By <br /> Destruction Inspection By Date <br /> COMMENTS: <br /> PE SC AMOUNT CHECK#/ RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# <br /> CODES INFO REMITTED CASH BY <br /> aS s mig <rtpo S2o ag <br />