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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 /> � <br /> NON-REFUNDABLEPERMITPERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> 7 <br /> JOB ADDRESS t�3 2 LfS t� u-C' 111 Rj/ <br /> �f /J r <br /> PARCEL SIZ&APN !¢ <br /> T� CYC S CITY/ZIP i <br /> OWNERN �L 'v��t'�'" ��DRESS PAYMENT <br /> CITY/ZIP L X PHONE <br /> CONTRACTOR �- ![S r iSkDDRESS �I' ��yoc�S N 0 V 6 2000 <br /> CITYrIIP PHONE��2-4: CAN JOAQUIN COUNTY <br /> PUBLIC EALTIrSt � <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP_ RANGE_SECTION <br /> TYPE OF WELL: NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL N ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL N <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL N ❑SOD.BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> r <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA/ CONDUCTOR CASING DI <br /> MESTIC PRIVATE /�GRAVEL PACK/SIZE WELL CASING TYPEC WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL V❑DRIVEN GROUT SEAL DEPTH AvSPECIFI ATION/ <br /> 24 r-'R iV OTI C E <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME � a, 1 <br /> �,, //'' —� <br /> ❑MONITORING R E O L.1 FST E p GROUT SEAL PUMPED: ltitYES 13O <br /> ❑CHRISTY BOX ❑STOVE PIPE Ini�_F C)F 3 C-TICDNS/>L_L CONCRETE PEDESTAL BY DRILLER: '❑YES _ ���N` <br /> APPROXIMATE WELL DEPTH _ <br /> PROPOSED CONSTRUCTION/DRIUING METHOD: MUD ROTARY xAIR 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 ORDDIIAANCES,,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: <br /> TITLE: DATE: <br /> n <br /> V' <br /> DEPARTMENT JJSE ONLY r �l �j <br /> Application Accepted By �^ ��`�-" — Date 6 �V Arcs/� <br /> Grout Inspection By Date�mp inspected By Date <br /> Destruction Inspection By J (�j Date <br /> CO ENTS: 1 I IS— 07 13� �7�Y`�`t' SQ—OC7—��S I — �1 —OOC� S <br /> z <Y-r2- <br /> PE SC AMOUNT HEC RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# <br /> CODES INFO REMIT ED ASH BY <br /> leo L �C353 /i� �� 512pI�� <br />