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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC?TEALTH SERVICES ENVIRONMENNUAL HEALTH DMSION <br /> 304 E.WEBER AVE., STOCKTON CA 45262 (209)46H-3420 <br /> NON•REFI.NDA%L PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IOE ADDRESS_Ho <br /> PARCEL SIZPJAPN � CITY/zip(��( CITY/zip <br /> OWNER NAME 1 1.p} rLDDRESS ��— iraR <br /> CRvr2p PHONE <br /> CONTRACTOR_ j� 4DDRESS 1 <br /> CITYr22P��952) _ PHONE <br /> GEOGRAPHICAL ` <br /> INFORMATJON: COORDINATES X� Y_TOWNSHIP— RANGE—SECTION <br /> TYPE OF WELL: Q NEW WELL BPLACEMENT WELI. ❑ MONITORING WELL X O OTHER <br /> INSTALLATION: �F'ELL SYSTEM REPAIR ❑CROSS•CONNECI REPAIR ❑VAPOR EXTRACTION WELL a <br /> TYPE OF PUMP-. a REPAIR H.P. 1— DEPTH PUMP SET -e�6 FT. FII2ST'WATER LEVEL <br /> ❑OUT-OF•SERVICE WELL ❑CEOTECHNICAL# 1 O SOIL BORLNG ❑DFSTRUCTION: <br /> INTFt NDF.D US_F, TVPF OF WELL CONSTRUCTION SPF,CiIV_1CAIM <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> 41(5�MESTIC PRIVATE ❑GRAVEL PACKlSIZE WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLICJMUNICIPAL ❑DRIVEN GROUT SEAL DFXTH SPECIFICATION <br /> ❑IRRIGATIOMAG OTHER GROUT BRAND N <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES 0 NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL.BY DRILLER: ❑YFS ❑NO <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY_AUGER_CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICAT SON AND THAT THE WORK W ILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY <br /> O/R{DIIAN'CC�ES,STATE LAWS,AND RI LES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: l ,'��L�Llnj i' — <br /> TITLE: / DATE• Y I ` ` <br /> KWjuL- <br /> vt <br /> i <br /> i I I <br /> i <br /> i <br /> t 1 <br /> I <br /> DEPARTMEN SEONL <br /> Application Acccplcd By au <br /> `Arca <br /> Grout Insp=ion By Date Pump Inspected By <br /> Destruction Inepxtioa By. Datc <br /> COMMENT'S: W64E D< YAi'0"44 <br /> PE SC AMOUNT HEC RECEIVED DATE P (SERVICE REQUES WELL IDp <br /> CODES LNFO REMITTED H BY <br /> i�- <br />