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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIMION <br /> 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> A� <br /> JOBB ADDRESS �cX�U��� Lylg?i� el < <br /> I`PAtSIIFJAP r-O/ min lV !�C'1IIYIZIY <br /> OWNER NAME A iCL I S�L12-"'AbDRESS <br /> CITYlZIP S��}�,� �y1/i /,/y a� PHO"" t .l �1:�- ZO FS <br /> CONTRACf01�%C.Yycwzy' �7(�� ADDRESS /¢^11 `•/�flq��A/�` ��a�-' <br /> CITY/ZIP � PHONE <br /> GEOGRAPHICAL INFORMATION:COORDINATES X_ Y:TOWNSHIP- RANGE_SECTION <br /> TYPE OF WELL: Q NEW WELL PC REPLACEMENT WELL Q MONITORING WELL#`---0 OTHER <br /> INSTALLATION: Cl WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> CYTE OF PUMP: NEW Cl REPAIR H-P. DEPTH PUMP SET__�_FT. FIRST WATER LEVEL �� r <br /> OUT-OP-SERVICE WELL ❑GEOTECHNICAL!i ❑SOIL BORING-- ❑DESTRUCTION:_ <br /> I�,'QDED USE TYPF.OF WELL CONSTRUCTION SPF,CIFI AC TIOLlN <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIAD CONDUCTOR CASING DI �� <br /> LA` <br /> �OMESTIC PRIVATE 13 _GRAVEL PACK/SIZEWELL CASING TY?E A WELL CASING DIAD <br /> 4 PUBLICMIUNICIPAL $2IVT€H R N OT I CE GROUT SEAL DEPTH IMI SPECIICATION G4'5a <br /> D IRRIGATIOMAG Ft E(ZZU E ST F_O OTHER GROL'T BRAND NAME Y/'p <br /> FC-)R ALL .�s <br /> O MONITORING 1 N S P ECT I c)N S GROUT SEAL PUMPED. NO <br /> ❑CHRISTY BOX O STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES _A;10 <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY 4 AUGER CABLE_OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED TIUS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN-�J��j�� N E LAWS,AND RULES AND REGUii.ATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: ( � � <br /> z <br /> TITLE: <br /> 10 t <br /> 111117 <br /> 1 <br /> I A I I <br /> ' <br /> DEPARTMENT USE ONLY f <br /> Application Accepted '10ate Atex Zi <br /> Grout Inspection By Dam Pump Ins ed By <br /> Destruction Irspecti <br /> �r� Date <br /> COMMENTS: <br /> i <br /> PE SC AMOUNT C RECEIVED DATE PERMITlSERVICB REQUESTk Ok <br /> CODES INFO REMITTED CASH BY <br /> o 7-16 <br /> ,. <br /> 5CO <br />