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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 1 YEAR OM DATE ISSUE <br /> JOB ADDRESS eq`� r <br /> PARCEL SIMAPPN =/ZIPCi <br /> OWNER NAME/ RESS 3 �►�/��l� - ---- <br /> CITYfLIP w Pf10NE /) _ n <br /> CONTRACIiOR / ADDRESS /7 �2 / / r _fir r ', / � (J �" <br /> CITY/ZIP L-- PHONE ���C�Li off- �Y P- — <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP_ RANGE_SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: WELL SYSTEM REPAIR ❑CROSS-CONNECT REPABZ ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑NEW PQ2EPAIR H.P. DEPTH PUMP SET_ �-A Fi. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING _ ❑DESTRUCTION: <br /> INTENDED USE. TYPE,OF WELL, CONSTRUCTION SPECIFICATION <br /> AINDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROAT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> i <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCRON/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDIANCES TE LAW AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SI NED: <br /> TITLE:-, � - --'--DATE: ---- - -- — — <br /> #v"IVIP:1-11 C., W%-�- <br /> _ t <br /> /XIN <br /> II I <br /> � � I <br /> "NV N <br /> �,{ DEPARTMENT USF.ONLY <br /> .AppliFationAccepte fiy -� Date M Area ` 0 <br /> Grout Inspection By Date Pump Inspected By {� Datc 00 <br /> Destruction Inspection By Date <br /> COMMENTS: <br /> PE SC AMOUNT -CHECK# RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# <br /> CODES INFO REMITTED By <br /> 3 a!§V u u3 3 av a�2 0 2 <br />