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WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTII SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> t y 304 E.WEBER AVE., STOCKTON CA 43202 (209)468-3420 <br /> F� v <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r <br /> JOB ADDRESS <br /> PARCEL SIIFIAPNN cm/z1P <br /> OWNERNAME ADDRESS. 1/2,+re— <br /> '19 <br /> CITY/zIP A&C PHONE � 0 j <br /> CONTRACTORLAJlm"cDla4ll�n- dwt-ADDRESS ` <br /> , r�'� <br /> CITYrIIP `%,a 7 S3 d l PHONE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP_ RANGE_SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL M ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL.4 <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. I 1• Z DEPTH PUMP SET FI'. FIR--sT WATER LEVEL. /0 <br /> ❑OUT-OF-SERVICE WELL L7 GEOTECHMCAL N _-- ❑SOLL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CON&TRUCTION SUCIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELT.hXCAVATION DIA CONDUCTOR CASDVG DIA <br /> ?IWO / fr <br /> MT;STIC PRIVATE ❑GRA VEL.PACLU51LL WELL CASING TYPE -(/'�• - WELL CASING DIA l0 <br /> ❑PUBLLCJMUMCIPAL ❑DRIVL_N GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG 24 "F=l Iii QT'`-'' OTHER GROUT BRAND NAME <br /> ❑MONITORING R FQ R�A LL � GROUT SEAL.PUMPED. O YES 13 No <br /> ❑CHRISTY BOX ❑STOVE PIfN S P CTI CD N S CONCRGTF PEDESTAL BY DRILLER' ❑YES O NO <br /> i <br /> APPROXIMATE WE L DEPTH <br /> PROPGSED CONSTRUCTION/DRLLLLNG METHOD: MUD ROTARY AIR ROTARY At CABLE OTHER <br /> 1 IiEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQTIIN C UNTY ORDIANCES,STATE LAI►'S,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: <br /> TITLE: DATE:4-1 <br /> JkA <br /> I CJO O <br /> I <br /> I <br /> I � � <br /> — 1 <br /> - <br /> t <br /> N 'J INT <br /> P Hll H; ci` <br /> DEPART T ONLY <br /> Applicuinn Accepted By L ` ate l tp,Vca <br /> Grout Inspa:uon By Date Pump Inspected ey• G4 ZJDarc � <br /> l <br /> Dcwwtion InFpcction By Dote <br /> CEN:sG V 1 �(Q�fi'2Y�Gi 4�f1 _1-49k& ZII cl .IS_ Lv,,r%,- J'l/� <br /> TE Sc AMOUNT CIRC / RECEIVED DATE 1T/SERV1 �ST N WELL IDM <br /> CJDES INFO REMITTkD SH BY <br /> Z13 '� wp no <br />