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WELL/PUMP PERMIT PUMP <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 EXPI 1 YEAR.YR9M DATE ISSUED <br /> JOB ADDRESS a <br /> PARCEL SIZFIAPN CITY/ZIP / <br /> OWNER NAME DRESS ��d�Z a ( <br /> CTT'YlZIP_ v PHONE <br /> CONTRACTOR_ j r( L) ' AC_ADDRESS0 m� <br /> CTTYlIJP /�� VLL�a�/ —PHONE— <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE_SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL M _❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL A <br /> TYPE OF PUMP: $NEW ❑REPAIR H.P. r. DEPTH PUMP SET FIRST WATER LEVEL I I <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL M ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> 'I,DOMFSTIC PRIVATE ❑GRAVEL PACK/SIZE WELL. CASING TYPE WELL CASING DIA <br /> ❑PUBLICIMUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRtdTE PEDESTAL BY DRILLER: ❑YFS ❑NO <br /> APPROXIMATE WELL DEPTH P6 I <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTA,ZY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPAREDTHIS APPL CATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORD ,STATE LA ND R ANL`REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: _ <br /> TITLE: DATE: !7Ila l <br /> G <br /> KAo� <br /> r. I� <br /> / BL hi d.L :i[f <br /> DEP RTMENT USE ONLY `� <br /> Application Accepted.By Date /v (3 Ate. <br /> Grout Inspection Fy Date Pump Inspected By <br /> Destruction Inspection By Date <br /> COMMENTS: k <br /> PE SC AMOUNT KM R ATE UEST M WELL TDO <br /> CODES —L?!Lo4I REMITTED H BY <br /> ' goao v58'9 a z S,ecro s �a 3 z3�8 <br />