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e0N 9/6- v a <br /> W`w L/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUE 3ALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBEh...c., STOCKTON CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS g� 4r f fJ�� ��� �y<< GSLGj "j'16'13`j <br /> PARCELS // C1TYrIIP �'pp�<^ rCA els-7.37— <br /> OWNER <br /> J S 7— <br /> OWNER NAME 1:✓h w er 1 ��i?7 u 1 Y� ADDRESS SLY 01i <br /> L) <br /> CITY. `ITLu.� "1 J� p PHONE �c f-1 T, r�C�/b r/�JC Z�� '� ]•.a1 g <br /> CONTRACTOR I e,fvAe .,t 0 G u t II ADD S c, Pur �J� c��"r-I � / c p <br /> CITY//ZIP L c J CA 7 S t!!�14 PHONE <br /> I. <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP_ RANGE_SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL y[ MONITORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET Ff. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIAJE�L CONDUCTOR CASING DIA 14 <br /> ❑DOMESTIC PRIVATE )d GRAVEL PACK/SIZE43 4 WELL CASING TYPE�r WELL CASING DIA �r <br /> ❑PUBLICIMUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG 24 H R N C7TI C E OTHER GROUT BRAND NAME <br /> XMONITORING R E C�U E STE ID GROUT SEAL PUMPED: ❑YES ❑NO <br /> FUCK A! L <br /> ❑CHRISTY BOX XSTO VE PIP4rN S P E CTI C)N S CONCRETE PEDESTAL BY DRILLER: 13 YES ❑NO <br /> J <br /> APPROXIMATE WELL DEPTH 0 <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER A CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 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 /> 'R ,it rGw <br /> •H•H,E; �__"`�.r.Yl�v DATE: <br /> h <br /> zz <br /> 7 —T— I r —Awf <br /> LA I <br /> 77 ;01 <br /> 11 W�u <br /> , <br /> DEPARTMENT tjSE ONLY <br /> Application Accepted B Dat.—I-0 <br /> Grout Inspection D_ A Pump Inspected By Date <br /> Destruction Inspectio y Date <br /> COMMENTS:• F I�� '31 nn <br /> t L (. 1 <br /> PE SC AMOUNT HECK#/ RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# <br /> CODES INFO REMI BY <br /> 5 ��2raSs LC <br /> C'/ 0 f i• �C f7.� -G-f Z C4 �LC'`l <br />