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•.. WELL/PUMP PERMIT <br /> SANjJyOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTFI DIVISION <br /> 304 E.WEBER AVE., STOCKTON CA 95202 <br /> arn <br /> (209)468-3420 <br /> /,/ NON-REFUNDABLE PERMIT EX IRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS L{/ �J <br /> PARCEL SIZE/APN !q.'Y j <� CITY/ZIP �✓, " <br /> OWNER NAME. r— i— 'PS �ADDRESS ai^/�. <br /> CITY/ZIP i^ /J�� 0 PHONES� �.� T� 00 c <br /> CONTRACTOR L /^/. ADDRES //V•(� ^1©^/� "l /•_Q 5 .` <br /> CITY/ZIP I PHONE_ (O 7' g�( / 7 <br /> GEOGRAPHICAL INFFOORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: le NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR 11 CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> k <br /> TYPE OF PUMP: NEW ❑REPAIR H.P. _ DEPTH PUMP SET /50 FT. FIRST WATER LEVEL 670 <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION ' <br /> t" <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> 8 DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE� WELL CASING TYPE i„ WELL CASING DTA W <br /> A7 <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH QD SPECIFICATION A7 �d <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME (Mh Lt/' <br /> ❑MONITORING GROUT SEAL PUMPED: b 'ES ❑NO \ <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: fr ES ❑NO <br /> APPROXIMATE WELL DEPTH 711 <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY A[R ROTARY AUGER CABLE OTHER <br /> — <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: <br /> TITLE: DATE: 10L <br /> 1 ! 1= <br /> Aw <br /> t <br /> DEPARTMENT USE ONLY <br /> Application Accepted By _X41�`� Y "– Date C4 ('' v Area <br /> Grout Inspection By Date Pump Inspected By 6( �/ � Date <br /> Destruction Inspection By Date <br /> COMMENTS: <br /> PE SC AMOUNT CHECK#/ RECEIVED DATH PERMIT/SERVICE REQUEST# WELL ID# <br /> CODES INFO EMITTED BY <br />