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V v� WELL/PUMP PERNIIT­ <br /> SAN)vAQU1N COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE., STOCKTON CA 95202 (20)468-3420 <br /> i <br />' NON-REFUNDABLE PERMIT EMPIRES I YEAR FROM DATE ISSUED <br /> IOE3 ADDRESS 19690 N. HWY-99 <br /> PARCEL SIMAPN CITYMP <br /> OWNERIYAME AW R. {rf(,)RT! F HOME EMADDRESSRWY-99 <br /> CrrYrup� ACAMPn_ CA 99220 PHONE -2452 <br /> CONTRACTOR NDACK ADDRESS 4.500 E. FREMONT ST <br /> =mP STOCKTON, _CA 95215 PHONE (209) 948--817 _ <br /> GEOGRAPHICALINFORMATION:COORIJINATFS X__.,__ Y <br /> _TOWNSHIP__ RANGE^SECTION <br /> -TYPE OF WELL: R NEW WEU. O REPLACEMENT WELL O MONITORING WELL# 0 OTHER <br /> INSTALLATION: 01 WELL SYSTEM REPAIR O CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP. ❑NEW d(REPAIR H.P. 10 DEPTH PUMP SET-11-47---Fr. FIRST WATER LEVEL 57 <br /> ❑OUT-OF-SERVICE WELL II GEOTECHNICAL# ❑SOFL BORING ❑DESTRUCROM <br /> INTENDED USE TYPES CONSTRUCT30N SPEQFICAI•IODI <br /> 13 INDUSTRIAL 0 OPEN BOTTOM WELL EXCAVA77ON DEA CONDUCTOR CASING DIA <br /> li DOMESTIC PRIVATE 0 GRAVEL PACEUSIZE WELL CASING TYPE , WELL CASING DLA- <br /> 13 PUBLIOMUNIcipAL <br /> IA❑PUBLIOIMUNICIPAL [3 DRIVEN GROUTSEALDEPTH SPECIFICATION— <br /> C3 <br /> PECI KATIONF]IRRIGATIONIAG 24 H Fi NOTICE OTHER GROUT BRAND NAME <br /> Cl MONITORING R EQ U ESTE C] GROUT SEAL PUMPED: O YES 0 NO <br /> FOR ALL <br /> 17 CHRISTY Box ❑sTOv4MS P E c--Ti O N S CONCRETE PEDFSTAL BY DMLER: ❑YES o NO <br /> APPROXIMATE WELL DEPTHv ,3,115" <br /> PROPOSED CONSTRUCTIOWDRILLINGMETHOD: MUD ROTARY_AIR ROTARY AUGER CABLE: OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE W ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDIANCES,STATE LAWS,AND RULFS ANDREEGGULATIONS OP SAN JOAQUIN COUNTY. <br /> SIGNED: MCK TAYLORr <br /> TITLE[: RETAIL SALES �- HATE. 4-26-00 <br /> I <br /> I <br /> r• u+ <br /> �l <br /> Pr <br /> .f: <br /> ERE———— <br /> DEPARTMENT USP ONLY !'l1 <br /> Application Accepted BY Dme a Arc <br /> Grout Inspcetivrt Hy Dale Pump Inspected By4/ <br /> Drglnrction Inspection By Datc <br /> COMMENTS: a 'el 4 c Zz 6&ZT=eZ 1[3' <br /> QCs c/_s LC <br /> PE Sc AMOUNT CHECK/ RECEIVED DATE PERNUTtSERVICEREQUEST* WELL TD# <br /> ODES INFO REMITTED BY <br /> !`v, 46DA-clog <br />