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WELL/PUMP PERMIT <br /> SANJOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH D N <br /> 304 E.WEBER AVE, STOCKTON CA 95202 (209)468-3420 <br /> I O SSI /�(µO,mn /+ <br /> JOB ADDRESS vEISSUEDRyIT[EXPIRES 1 YEAR FROM DATE ISSUED <br /> PARCEL SIWAPN R v O+[ t s CCITY`ArLiP(y►`/ A-r,,n,2L, Uq (JY <br /> OWNERNANM&/ UO/t00eVir1ceNz6ADDRESS C.-04,.j IGIA <br /> CITYILIP c+f^I Lam" PHONE <br /> coN7RACIoR_/ _.-aq+`-& :'_0141 — ADDRESS <542 0 1A 1 C CF CAAWED <br /> CITY/ZIP rI ay LAI�C e, koe PHONE Ls'3 1--?:2u I \ 6s,[ tntn+r— Y <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y TOWNSHIP_ RANGE_SECTION <br /> TYPE OF WELL: If NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROoS..S--coNNECT REPAIR 13 VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: jV NEW ❑REPAIR H.P._y570 DEPTH PUMP SET I �I FT. FIRST WATER LEVEL /001 <br /> 3_�M-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOH.BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA apt CONDUCTOR CASING DIA= <br /> t• <br /> ❑DOMESTIC PRIVATE GRAVEL PACK/SIZE_ WELL CASING TYPE—S- WELL CASING DIA IX <br /> ❑PUBLICIMUNICIPAL ❑DRIVEN ROUT SEAL DEPTH SO` SPECIFICATION <br /> 24 HR LACTIC <br /> ArIRRIGATIONIAG R E Q U E ST E ID OTHER GROUT BRAND <br /> ❑MONITORING FOR ALL GROUT SEAL PUMPED: 10 YES ❑NO <br /> INSPECTIONS <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER ❑YES t#NO <br /> APPROXIMATE WELL DEPTH -1 r7 I <br /> / PAYMLIv; <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD:MUD ROTARY_AIR ROTARY—ZAUGER CABLE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN 4CCORDANCE WITH SAN <br /> JOAQUIN COUNTY,ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY.I <br /> 4 <br /> SAN JUAill,rtv t;GUN7 <br /> SIGNED: �.a[ PV30C , <br /> ry :rN'A; <br /> TL <br /> TIE: ATE: -�a-G7' <br /> W-elt. O%AF o' e- :-r to-P 0 -e- I' cC� <br /> I <br /> I <br /> + c <br /> I <br /> t <br /> c <br /> �•_ / <br /> Application Accepted By "`v v �`G' Lr DEPARTMENTUSE ONLY Date ZJ () Area �[, <br /> Grout Inspection By I a r�Pump Inspected By-r:---)a.22ff4�t./L✓ Date ��2�� <br /> Destruction Inspection By I Date <br /> COMMENTS: zl��Q��'l�\'d <br /> PE SC AMOUNT OJECKW RECEIVED DATE P T# WELL IDA <br /> CODES INFO NT <br /> ASH BY <br /> VIII � o�3 � 1_A3 <br /> t <br />