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r <br /> WELL/PUMPPERMIT <br /> SAN JOAQUTN COUNTY PUBLIC HEAI.TH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304E WEBER AVE., STOCKTON CA 95202 (209)463-3470 <br /> CI NONREFUNDABLE PERMIT 7y YEAR FROM DATE ISSUED <br /> JOB ADDRESS /97ai <br /> PARCEL SEZEJAPN CITY&LIP <br /> OWNERNAME a ADDRESS �a •tL I ��. <br /> ClTyl'� PHO <br /> CONTRA L L�� DRESS <br /> CRY21P_��n �0.— Y o�{,1PHONE C/ <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSRTP_ RANGE_SECTION <br /> TYPEOFWELL< O NEWWELL O REPLACEMENT WELL O MONITORING WELL# 13 OTHER <br /> INSTALLATION: O WELLSYSTEM REPAIR O CROSSLONNECT REPAIR O VAPOR EXTRACTION WELL# <br /> TYPE OP PUMP: )qNEW ❑REPAIR H.Pc?k DEPTH PUMPSET 4,FT. FIRST WATER LEVEL/L2.1- <br /> 0 OUT OF SERVICE WELL OGF.OTECHNICAL# OSOMBORINO ODTSTRUCHON: <br /> INTENDED USE XM OF WELL CONSTRUCTION SPECIEICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA_ CONDUCTOR CASING DIA_ <br /> DOMESTIC PRIVATE O GRAVEL PACK/SIZE WELL CASINGTYPE WELLCASWGDIA <br /> CI PUBLIC/MUNICIPAL ❑DRIVEN GROUTSEALDTiPIN SPECIFICATION- <br /> 0 IRRIGATION/AG OTHER GROUT BRAND NAME <br /> -- <br /> 0 MONITORING GROUTSFALPUMPED: OYES ONO <br /> O CHRISTY BOX O STOVE ME CONCRETE PEDESTAL BY DRI LER: O YES O NO <br /> APPROXIMATE WELL DEPTH Iy�a-e�J <br /> PROPOSEDCONSTRUCTIONAMMLMMETHOD: MUD ROTARY_AIR ROTARY_AUGER_CABLE_OTHER_ i <br /> I HEREBY CERTIFY THAT l HAVE PREPARED THIS AP LIGATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNT CES,STATE ,AN LES AND REGULATIONS OF SAN JOAQUIN COUNTY. , <br /> SIGNED: 7 <br /> TITLE: _DATE: <br /> A <br /> RI <br /> 0 <br /> USE ONLY <br /> APPlicatiai AccepleR BY— <br /> G., <br /> T G.,Inspection 9y Due Pump Ins DAte_ <br /> Dmmction Inspection By Date <br /> COMMENTS: <br /> PE SC AMOUNT jZSU3M>j RECEIVED DATE ICEREQUEST# WELL'DO <br /> CODES INTO REMITTED I CASH I BY <br /> ju ee%=F Zb .:Z-33 3 <br />