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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HFAI:TH SERVICES ENVIRONMENTAL.HEALTH DIVISION <br /> Q �y 304 E.WEBER AVE.. STOCKTON CA 95202 (209)46R-34 <br /> (�pTi7 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE 1 /RE <br /> JOB ADDRESS­ 0-V,,IT ;cQ��V.SQ P J Coe <br /> PARCEL SIZFJAP\ ?a _OCLTYIIIP I t b? .j C, <br /> OWNER NA.M• —ADDRESS----3 I-�Q ma r <br /> CoIv <br /> CTTY/LIP PHONE t' <br /> CONTRACTOR ��aeo =nom G�a �kj ADDRESS <br /> LT1�C1 TtOLL�2 _ <br /> CYlZIP n.n 4 T`���HONE `1a5� i a, -C p <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y_TOWNSHIP_ RANGE_SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL M M(OTTIER C�� <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL 0 <br /> TYPE OF PUMP: O NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL G/GEOTECHNICAL tl40 CrLs ❑SOIL BORING ❑DESTRUCTION: _-._ <br /> INTENDED USE TYPE OF WELL LtO CONSTRUCTION SPECIFICATION <br /> ❑INDUS'T'RIAL ❑OPEN BOTTOM WELL EXCAVATIO\DIA CONDUCTOR CASING DIA <br /> ❑DOMF571C PRIVATE ❑GRAVEL PACK/SIZE— WELL CASING TYPE WELLCASING DLA <br /> ❑PUBLICIMUNICIPAL ❑DRIVEN GROUT SEAL DEPTH 4 , SPECIFICATION CnmQlAka <br /> ❑IRRIGATIONlAG OTHER GROUT BRAND NAM]------ <br /> C3 <br /> AM] ____❑MONITORING GROAT SEAL.PUMPED: ❑YFS ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YFS ❑NO <br /> APPROXIMATE WELL DEPTH � <br /> s <br /> PROPOSED CONSTRUC IONIDRILLING MEI'HOD: MUD ROTARY_AIR ROTARY_AUGER CABLE OTTIER CF N <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND TIJAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDIANCES.STATE LAWS,AND RULFS M10 REGULAnONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: /1 <br /> I <br /> I <br /> — i- <br /> i <br /> I <br /> t � <br /> V-1 <br /> - 1 - - <br /> I <br /> _qtt- <br /> -H�L <br /> QM_EMyjq�S{�'ONLY /y /7_/'- <br /> Application Accepted By `�""�+�`^ f 1 eVs\ �---- --Date-_I` 1_- K `-' AIT - <br /> Groot Inspection By Date—Pump Inapectcd By —. .... _ ... Date <br /> Destruction Inspection By <br /> COMMENTS: <br /> PE SC AMOUNT ,CHECK-q RECEIVED DATE PERMIT/SERVICE REQUEST k WELL IDO <br /> CODES INFO REMITTED BY <br /> Z f 5DO12- /o I <br />