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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 /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS D /v w1 `''�L/ //,&14� !_ A" <br /> PARCEL SIZE/APN �p CITY/ZIP '0 0 - J <br /> OWNER NAMEG6 0(LIL' 644SC A ADDRESS SKI CS <br /> CITY/ZIP Z> t PHONE <br /> CONTRACTOR <br /> I '46ir/�I�I2j(��� ,( ADDRESS L/ <br /> CITY/ZIP(,N C�WJ 1121tt�2 4< (o,/� PHONE2-5 t ILL LOWY <br /> / <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION.-- <br /> ,49VWLLZYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: �IEW 13J /REPAIR H.P. DEPTH PUMP SET r ` -2 FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# Cl SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA _ CONDUCTOR CASING DIA <br /> OMESTIC PRIVATE GRAVEL PACK/SIZE WELL CASING TYPE p v(- WELL CASING DIA_ <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH� SPECIFICATION <br /> ❑IRRIGATION/AG 2'4- HIR N OTI ,ESHER GROUT BRAND NAME CZS 6_&t <br /> REQUESTED <br /> ❑MONITORING FOR ALL GROUT SEAL PUMPED: YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE I P E Cf.TI O N�NCRETE PEDESTAL BY DRILLER: )9YES 11NO <br /> APPROXIMATE WELL DEPTH v <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY/N 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 LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: <br /> TITLE: DATE: 2,-3 - 01 <br /> n <br /> f <br /> I <br /> r <br /> Ft\I fl ,4F ai a � ie <br /> / JJ DEPARTMENT USE ONLY <br /> Application Accepted By��W Date 3 t�7 <br /> Grout Inspection By USA Date2 8.0 Pump Inspected By Date — <br /> Destruction Inspec',o y <br /> 28Date <br /> o� 33� <br /> COMMENTS: 411 jCAgK-sww)-_> o Cop pgmp -0o t (, -20o frour <br /> PE SC AMOUNT &CHECK#j RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# <br /> CODES INFO REMITTED BY r _ <br /> or <br /> OsV <br /> 3- Iry o n aac q <br />