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/��(1�.� <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN CUUNTI'PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> ' J <br /> PARCEL SIZE/APN CITY/ZIP A. L,-,\-. <br /> OWNER NAME ^J /D ADDRESS �r�_ „✓t <br /> CITY/ZIP ) w PHONE <br /> CONTRACTOR �ADDRESS / <br /> CITY/ZIP ()C-/l 77 PHONE <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 REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW I kkEPAIR H.P. DEPTH PUMP SET �FF. FIRST WATER LEVEL J 3 <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL, CONSTRUCTION SPECIFICATION <br /> ❑ INDUSTRIAL ❑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 GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> n � <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTIONlDRILLING 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,STATE L YIS5,ARULES AND REGULATIONS OF SAN,IOAQUIN COUNTY. <br /> SIGNED: <br /> TITLE: 2 l`P DATE: <br /> I <br /> i <br /> I <br /> I <br /> I <br /> ;r,U' <br />