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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> f 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUE) <br /> JOB ADDRESS ' <br /> PARCEL SIZElAPN CITY/7IP '3 7� <br /> Y <br /> OWNER NAM$ ADDRESS <br /> CITY/ZIP PHONE <br /> CONTRACTOR t ADDRESS O <br /> i CITYrLIP 3 d PHONE 5 r <br /> y <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> i 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 ❑REPAIR H.P. [3]ti0— DEPTH QG 3ET__JLO �FT. FIRST WATER LEVEL <br /> f ❑OTlT-OF-SERVICE WELL 0 GEOTECHNICAL# 0 SOIL BORING ❑DESTRUCTION: <br /> f <br /> i INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> .g DOMESTIC PRIVATE ❑GRAVEL PACKISIZE WELL CASING TYPE WELL CASING DIA <br /> y <br /> I ❑PUBLIC/MUNICIPAL Q DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> �- ❑CHRISTY BOX ❑STOVE PIPE <br /> r7 CONCRETE PEDESTAL BY DRILLER: 11 YES ❑NO <br /> APPROXIMATE WELL DEPTH /b <br /> + PROPOSED CONSTRUCTIONIDRILLING 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 /> t JOAQUIN COUNTY O IANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, <br /> f t C <br /> :g SIGNED: yy <br /> TITLE: DATE: <br /> i <br /> IE: <br /> k <br /> ,p <br /> i <br /> i <br /> i <br /> y <br /> f . <br /> f <br /> C"a —DEPA TMENT SE ONLY <br /> Application Accepted By L'" Date �� Area <br /> :i <br /> t Grout Inspection By Date Pump Inspected By Date <br /> Destruction Inspecttiiion By Daie <br /> y COMMENTS: et m 4 a c>ij oa av <br /> i <br /> +,f <br /> PE SC AMOUNT CHEC / RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# <br /> CODES INFO REMITTED SH BY <br /> �:I <br />