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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> JIHE WEBER AVE., STOCKTONCAY5202 (209)N683420 <br /> NON- /�UNDABL T EXPIRES I YEAR FROM DATE ISSUED (J <br /> JOB ADDRESS EJI!//J_A��,l/e I I B P r Z7 <br /> PARCEL ST APN /pp VO CRYMP 1/ <br /> OWNER NAME el A ADDRESS WL O <br /> CITYMP PHO <br /> CONTRACTOR it Z ADDRESS-... •� G��L1-�� <br /> CffYlIJP T�� — C PRONE V-6 .s2 — 1 LI <br /> GEDGRAPHICALINFORMATION: COORDINATES X Y_TOWNSHIP_ RANGE_SECTION <br /> TYPEOFWELL: ❑ NEWWELL ❑ REPLACEMENT WELL ❑ MONITORING WELLY ❑OTHER <br /> INSTALLATION: ❑WELLSYSTEM REPARt ❑CRO55-CONNECT'REPAR2 ❑VAPOR EXTRACTION WELL Y <br /> TYPE OF PUMP. ❑NEW Y;REPA[R H.P. � DEPTH PUMPSET FIAST WATER LEVFI <br /> r ❑OUT�OFSERVICE WELL ❑GEOTli H ICALY ❑SOIL BORING ❑DESTRUCTION: <br /> INTEMMUSE TYPE OF WELL CONSTRUCTIONSPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELLEXCAVATIONDIA CONDUCIORCASINGDIA <br /> XDOMESRCPRIVATE ❑GRAVEL PACK/SI WELLCASINGTYPE WELLCASINGDJA <br /> ❑PUSLIC/MUNICIPAL ❑DRIVEN GROUTSEALDEPITI SPECIFICATION <br /> ❑IRRIGATIOWAG OTHERGROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOK ❑STOVE PIPE / CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> ,[ J <br /> APPROXIMATE WELL DEPTH '{5 <br /> PROPOSED CONSTRUCDON/DRIJ.ING METHOD: MUD ROTARY_AI(ROTARY_AUGER_CABLE_OTHER_ <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN RDIANCES,STAAWS, RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED / <br /> TRIS Pry f DATE://� I - <br /> G <br /> -------------- <br /> 1 <br /> EPARTMENT USE ONLY ,`1 <br /> Appli uo A« wl By Due1� —Art Z�2. (PJ/J <br /> Gmm IMPe WBY Due Pump Eupected HY { Datc '�-- <br /> Deumainn Inspxuon eY <br /> COMMENT'S: <br /> PE SC AMOUNT CHECKY/ RECEIVED DATE PERMR�SERVICE REQUEST Y WELL DM <br /> CODES INFO REMITIF.D CASH BY <br /> o s 21 a D SRo a <br />