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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL.HEALTH DIVISION <br /> 304 E.WEBER AVE., ST'OCKT'ON CA 95202 (209)468-3420 <br /> NON-REFUNDABLE ERM1T EXPIRES 1 YEAR OM DATE.ISSUE <br /> JOB ADDRESS 99 9 <br /> PARCEL SIZEfAPN CITYIZIP <br /> OWNER NAM .( RFss 3 / /"/l�':�j <br /> CITYlZIP _PHONE <br /> CONTRACTOR ADDRESS� Y <br /> CTTYIZIP�'^ PHONE <br /> GEOGRAPHICAL INFOWNIATION: COORDINATES X Y—TOWNSHIP_ RANGE_SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENTWELL ❑ MONITORING WELL N ❑OTHER <br /> INSTALLATION: P{WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WEU M <br /> TYPE OF PUMP: ❑ NEW P%EPAIR I1.P. DEPTH FUMPSET- /-;L/,, FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL M ❑SOIL BORING ❑DF-MUCTION: <br /> INTENDED USE TYPE OF WELL. CONSTRUCTION SPECIFICATIO14 N <br /> INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE_ WELL CASINGTYPE WELLCASING DLA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPI"H SPECIFICATLON <br /> ❑IRRIGATION/AG OTHER GROAT BRAND NAME• <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDFSTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE W'EI-LDEPTH �,C�O r4- <br /> PROPOSED CONSTRUCTTON/DLUL.L ING 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 /> i <br /> S1 WED: —"y - - -- _ --/- -- <br /> TITLE: I'/Qc DATE: X ZZ <br /> U V0647-c—w%-� I <br /> I I I <br /> I ! <br /> I - ! <br /> __- - -- <br /> I LL <br /> i <br /> Y._ <br /> - EIvV <br /> - t <br /> DEPARTMENT USE ONLY ? ^ � <br /> ,ApplicationAcccpted4,y _ ._._ Date" Lid AreaK13 <br /> Grout Inspcction By _Date Pump Inspected By (N_ _-- Dale � 00 <br /> Desmiction Inspection By-- _ —Date-- <br /> COMMENTS: <br /> ate _COMMENTS: <br /> PF: SC AMOUNT CHECK# RECEIVED DATE PFRMIT/SERVICE REQUEST M WELL IDM <br /> CODES INFO RHMITTED BY <br /> 3 <br /> 0 3 ov ouzo <br />