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IWELL/PUMP PERMIT PAYMENT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION RECEIVED <br /> 307E.WEBERAVE., STOCKTONCA95202 (209)468-3340 <br /> NDABLE PER.NIT EXPIRES 1 WEAR FROM DATE ISSUED SEP 6 2000 <br /> JOE ADDRESS NON-RE U 1 <br /> SAN JOAOUItJ COUNTY <br /> PARCELSIZEIAPN , ITY2n' �J�L`�p� .S EWHONWNTAL HFAI'H DNISIDN <br /> OWNERNAME �a <br /> C <br /> CITY lIJP y PHONE �J <br /> CONTRACTO `S I ( ADDRESSay <br /> 6Afy/ <br /> cnYrze-1110 'e <br /> PHONE-2E—'2— <br /> GUOGRAPJHCALINNFORMATION: COORDINATES X__ Y_1"WNSHTP_ RANGE_SECTION <br /> TYPE OF WELL: * NEWWELL ❑ REPLACEMENTWELL ❑ MONITORING WELL f___❑OTHER <br /> INSTALLATION: ❑WELLSYSTEMREPAIR ❑CROSS-CONNECTREPAIR ❑VAPOR EXTRACTION WELLY <br /> TYPE OF PUMP; ❑ NEW ❑REPAIR H.P_ DEPTH PUMPSEF PIT ofutsr WATER LEVEL <br /> ❑OCT-OF-SERVICE WELL ❑GEOTECIINTCALN CI_ BORING _ <br /> INTENDED LIST TYPE OF WFLNSTRUCTIONSPFC <br /> I COIfAI <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL]EXCAVATIONI`IA �ilZl� CONDUCTOR CASING DIA__ <br /> ROMFSTIC PRIVATE XRAVELPACRISIZE_ <br /> WELL CASING TYPE WELL CASING DIA // <br /> _yyyy��)) <br /> 13PUBLICJMUNICIPAL ❑DRIVEN GROUT SEAL DEFTH,;a � ? SPECIFICATION <br /> ❑IRRIGATIO WAG OTHER GROUT BRAND NAM <br /> ❑MONITORING `2-4 BAR !\10710E GROUT SEAL PUMPED: J1t ES ONO <br /> ter_-.c�u�s-rEo <br /> ❑CHRISTY BOX ❑STOVE PIPE FU CONCRETE PEDESTAL BY DRILLER: LIVES <br /> APPROXIMATE WELL DEPTH� CI IC <br /> PROPOSED CONSTRUCTIOMDRLLING METHOD: MUD ROTARY—KAIR ROTARY AUGER_CABLE_OTHER <br /> I HEREBY CERTIFY THAI 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE 1N ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDIIAN./C.EYS-,STATE <br /> LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY- <br /> SIGNED" <br /> TITLE: A�n t !�1�N DATE: <br /> • 1 <br /> if I <br /> } <br /> DEPARTNIEeNT USE ONLY /� T <br /> Application AwePlNylE�y� �"��� i�i.tiy� Date <br /> Grnut Inspection RYYJ.: T�4ceare Pump Inspected DY Datc <br /> Desvu.n.lnspecsi."y a y /� (� ^Data <br /> COMMENTIS Ui Vr\ 10X QtA.is9' k <br /> . — i 1.L4-0 Cl t'Al/Lt.rfl CL'�Y C(,/✓{�I I i <br /> ~v <br /> SCAMOUNT CH EIVGD DATE PE /SER VICE REQUESTN WELL IDN <br /> CODES INFO REMC D CASH BY <br /> ��','� Gb5 2bf 0175' L Yd O <br />