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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1• Z� <br /> 304 E WEBER AVE., STOCKTON CA 95202 (209)668-3420 <br /> RAEFFUUND LE PERMIT E IBES 1 YEAlt FROM <br /> jDAT,ISSUED <br /> TOR ADDRESS <br /> PARCELSIZFJAPN � CITYZP S� � <br /> 1 � <br /> OWNERNAM ✓Y I �_ADDRESS CCI�� 5 Leg,- <br /> CITY2IP PHO �/� <br /> CONTRACLOR_ `- �- ADDRESS �`(' J 't P •�- <br /> Cf1YrLIP_i�L �� I�PHONP a �.� <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y_TOWNSHIP_ RANGE_SECTION <br /> TYPEOFWELL: ❑ 13NEWWELL ❑ REPLACEMENTWELL MONITORING WELLq ❑ <br /> - OTHER <br /> ` <br /> INSTALLATION: )WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELLk <br /> TYPEOFPUMJ!. VNEW ❑REPAIR H.P DEPTH PUMPSET, ' '� . FIRSTWATER LEVEL <br /> 13 OUT-OF-SERVICE WELL ❑GF,OTECHNICALB ❑SOILBORING DDESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> �❑,TINDUSTRIAL El OPEN BOTTOM WELL EXCAVATION DIA CONDUCCORCASINGDIA_ <br /> ){DOMESTIC PRIVATE ❑GRAVEL PACK41ZE_ WELL CASING TYPE WELL CASING DIA- <br /> 0 <br /> IA <br /> r❑'PUBLICIMUNICIPAL ❑DRIVEN GROUTSEALDEPIH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME (A <br /> 0MONITORING GROUT SEAL PUMPED: r]YES 13 NO "1 <br /> ❑CHRISTY BOX 12 STOVE PIPE, CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY_AIR ROTARY_AUGER,CABLE_OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS PPIJCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN `�\P <br /> JOAQUIN COUNTY ORDIANCES,STATEL S,A RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> i <br /> SIGNED: <br /> I <br /> TITLE: • DATEfil : <br /> t <br /> I <br /> _ L <br /> H <br /> W IJ <br /> DEPARTMENT USE ONLY <br /> APPlkaflm AcceptM By Dnro <br /> Grout Itupmtion By Da¢ Pump Invpp wd BY etc <br /> Destruction W pmtion By Detc <br /> COMMFNTS: <br /> PE Sc AMOUNT 4 EC RECEIVED DATC PERMITlSERVICE REQUESTk WELLIM <br /> CODES INFO REMITTED H BY <br /> 3fv rSv .S-0- ;W57 2rZ `3D o 5'Qo03�597 ' <br />