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WELUTUMP PERMIT PAYMENT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION RECEIVED <br /> 304E.WEBERAVE., STUCKT'ONCA95202 (209)468-7420 <br /> NON-RE UNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED SEP 6 2000 <br /> JOB ADDRESS G SAN JOAOWN COUNTY <br /> PARCELSIZE)APN t TTY/Llp1 ..S ENNRONMRITAl BF4181 DIVISION <br /> A. <br /> OWNER NAMEC �' DRESS IL <br /> CITY/ZB'y Q" PHONE <br /> e t ( ��CCCLCC777//' <br /> CONTRACTOR S' P ADDRESS�� — <br /> clTYme�,rz <br /> GEOGRAPHICALINFOR3,1ATION: COORDINATES X, Y_TOWNSHIP_ RANGE—SECTJON <br /> TYPEOF WELL: 1p� NGW WELL E3RHPIACEMENT WELL 13 MONITORING WELLk ❑OTHER <br /> INSTALLATION: <br /> ✓✓✓✓❑��``WELL SYSTEM REPAIR ❑CROSS-CONNECTREPAIR ❑VAPOR EXTRACTIUNWELLN <br /> I <br /> TYPE OF PUMP: 13 NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FjRSr WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL k ❑SOIL BORING _ REQ <br /> INTENDED USF TYPE OF WELL ('ONSTRL CTION 'PFCIFICATI �I u 1 I ]✓ <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION VTA_,[A ._ CONDUCTOR CASING DIA__ <br /> DOMESTIC PRIVATE 04R,1VEL PACK/SIZE_ WILL CASING TYFE evz WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL El DRIVEN GROUT SEAL DEPTH SPECIFJCATION <br /> ❑IRRIGATION/AO OTHER GROUT BRAND RAM <br /> ❑MONITORING 24 IJ`R I\I�JTICE GROUT SEAL PUMPED JeQES ONO <br /> � <br /> ❑CHRISTY BOX 13 STOVE PIPE l-=� CONCRLTE PEDESTAL BY DRR"LER: ❑YES - �0 <br /> APPROXIMATE WELL DEYTH <br /> PROPOSED CONSTRUCITON/DRILLING METHOD:MUD ROTARY D AIR ROTARY_AUGER—CABLE—OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAI'THE WORK WILL BE DONE W ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDI/1ANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIX COUNTY. <br /> SIGNED: l'�C� F�1 a _ <br /> TITLE: tJ H I 1 L!'N DATE' <br /> I F_ <br /> DEPAR17MENTUSE ONLY 1 C�{d1l <br /> Application Accepted Myy , -�"`1�w_6.E+�� Date Y7/�X33-e d A,�2/2 <br /> Gmut Bmspecdon By /ute Nw Inspected 13 Dale, <br /> Destruction Inspemm By- yy � �((''�((�� ,�., � ,^, � tt .(� ..wwate�� ^_. <br /> COMMENTS:W �` ayk)6("A-"Li (L.+AX,P PIA,"'i. \2J CL CC`vyt�+_��iyk\l-\ <br /> G+— <br /> w <br /> .E SC AMOUNT VED DATE PE lSERVICEREQUF 10 WELL IDk <br /> CODES INFO REMITTED CASH BY <br /> XG)r? 1 . 017 '�G 96 0 <br /> Jn13z Gt!'Y9'� A l� <br />