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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br />304 E. WEBER AVE.. STOCKTON CA 95202 (209) 468-3420 <br />NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSIIr , ..... <br />1013 ADDRESS c79,&67o / AidelAgett, ke- i(Q.4 , <br />PARCEL SIZE/APN CITY/ZIP <br />OWNER NAME ADDRESS ADDRESS <br />CITY/ZIP PHONE F.3 le -.2 1 01S- <br />CONTRACTOR.X... .Aid-Ade" Zile...re , ADDRESS 1.9. P i ig,0214" 1 el <br />CITY/ZIP PHONE ff.31•-- .4.27y <br />GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION _ <br />TYPE OF WELL: 0 NF.W WEIL 0 REPLACEMENT WELL 0 MONITORING WELL ti 0 OTHER <br />INSTALLATION: EI WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR CI VAPOR EXTRACTION WELL 0 <br />TY rE OF PUMP: 1E1<E W CI REPAIR H.P. i ii 2.-- DEPTH PUMP SET tr. FT. FIRST WATER I.EV EL AST4 ' .,..q <br />o OUT-OF-SERVICE WELL 0 GEOTECHNICAL 0 0 5011. BORING 0 DESTRUCTION: <br />INTENDED USE TYPE OF WELL, c_QINST RUCTION SPECIFICATION <br />B34USTRIAL 0 OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br />CIP‘MESTIC PRIVATE 0 GRAVEL PACIUSIZE WELL CASINO TYPE WELL CASING DIA <br />0 PUBLIC/MUNICIPAL 0 DRIVEN GROUT SEAL DEPTH SPECIFICATION <br />0 IRRIGATION/AG OTHER GROUT BRAND NAME <br />0 MONITORING GROUT SEAL PUMPED: 0 YES 0 NO .., <br />0 CHRISTY BOX 0 STOVE PIPE CONCRETE PEDESTAL BY DRILLER: 0 YES 0 NO <br />.--. <br />APPROXIMATE WELL DF.PTH 3 !a 0 ' - ,. <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE 0 IIIER <br />1 I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQ(IIN COUNTY ORDIANCF.S, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. C <br />SIGNED: <br />di <br />AIM 41r-/ <br />TITLE. 4942,,o_... 7/41,0.172-1.--- DATE: ...2- ---'- CO <br />_I <br />.-- <br />LI ilaiii. '1 <br />Or <br />. 40, <br />, , <br />.,..„,.......i. . ,....,.........,,, <br />FED 16 2.Cu • <br />FAME SAN An d. , <br />iOnQuirn <br />*,EALIN <br />CUJN.' <br />' . r ENVIIICNM NTAI HAFT <br />SERVICES <br />_D VIS.rtu <br />DEPARTMENT USE ONLY <br />Application Acceptcd By DaLc ;2. -i e i0Arca /6 7 <br />Grout Inspection Bv DSC Pump Inspected By <br />Destruction inapectio B Date — <br />COMMENTS: -13 -20ao 6.)41.a. PEDISTIN- Reft4.4.61) <br />PE <br />CODES <br />SC <br />INFO <br />AMOUNT <br />REMITTED <br />HE <br />ASH <br />RECEIVED <br />BY <br />DATE PERMIT/SERVICE REQUEST** WELL IDR <br />930 asv i----0 -410.” 145 Job) SRI) c 2 .2 i r) 7