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WELL/PUMP PERMIT <br /> . SCANNED <br /> N SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENIHL HEALTH DIVISION <br /> 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED E L <br /> LSIZE/APN hOt 64PWbC0-bKtdf CITY/ZIP r4-p' Cf� 9523 4o <br /> OWNER NAME ADDRESS <br /> cw <br /> CITY/ZIP �00KI t (J� _t n✓r 3010 PHONE C�/"I J (J1J ' <br /> CONTRACTOR 1 ADDRESS �T✓L J�./LSL/ <br /> CITY/ZIP Cj�'t ►C, PHONE (v 1 l (O�^I '-' O 1 <br /> GEOGRAPHICAL INFORMATION: COORDINATES X a A Y tj A, TOWNSHIPN A RANGEI /�SECTIOONN N � <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL# �W' WJ❑OTHER <br /> INSTALLATION,:^ ❑ <br /> TYWELL SYSTEM REPAIR [3 CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> au <br /> OpP-E OF P 13R: W ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑OUT-O - ERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICIIAIITION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM �,� WELL EXCAVATION DIAD. CONDUCTOR CASING/DIA A <br /> ❑DOMESTIC PRIVATE 'IORAVEL PACK/SIZE I`V_Q '' WELL CASING TYPES WELL CASING DIA —T - <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN �'v GROUT SEAL DEPTH 10 F SPECIFICATION <br /> ❑IRRIGATION/AG 24 H R M OT I C L=THER GROUT BRAND NAME <br /> MONITORING R E Q U E S T E ED GROUT SEAL PUMPED: DYE ❑NO <br /> FCDR ALL- <br /> El <br /> LL❑CHRISTY BOX ❑STOVE PIPEIPo <br /> M S1E ?-)p M CONCRETE PEDESTAL BY DRILLER: YES ❑NO 1 <br /> APPROXIMATE WELL DEPTH 2 5 +0 .I 91+ J 61 I <br /> PROPOSED CONSTRUCTION/DRILLING 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 RDIANCES,STATE LAWS RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> / e- <br /> TITLE : <br /> SIGNED:: NU111"'k 0 a(Ak 1120. DATE: <br /> ie c,uaT <br /> aorH BM 1B <br /> 1 o <br /> • j ' OW <br /> IC O 1 IM OUA MM <br /> X660 <br /> SWfi <br /> � OCG US" <br /> t p OIS07CIBOOIM <br /> 1 <br /> N <br /> 4 .'3 iovcu c ovcucc awo <br /> ao.1D�A ! :O .ri• <br /> OIS07C18LOIr <br /> i <br /> SHARPE i �• Z <br /> GENERAL i g' <br /> DEPOT e ;0[MISTING WELL<STATC WELL 1W <br /> T <br /> aouace2 I . <br /> aD <br /> ON 18 = < <br /> M WT`•• OIS07C.1. <br /> a <br /> r <br /> � <br /> SITE[ ; M'W-3� <br /> p'0 01Sos62.NBtr ;; EC <br /> PROPO( YEV <br /> W." 2 :IiC l <br /> PN <br /> Uo'*:1►" <br /> - swaNMONITO INGp <br /> R;MW- WELL <br /> 0.MW-2 Mw_ •. <br /> y ral1 <br /> H Ih <br /> L.TNAO� ROAD N Ur <br /> r DEYAK"CIv1> <br /> Application Accepted By Date 1p•13Area <br /> Grout Inspection By Dat"Ovmp Inspected By Date <br /> Destruction Inspection By Date <br /> COMMENTS: SSC- V tK 10A'p 1, e-i- `5 i NPW�- bs 15cc n o.3 4- 3.4 - 30C t n-C FXCE51 <br /> C-i2 �z ��g 59b Sn-ret�ar_- 6 Jowmk IjA tFmEDIT eiflVuf <br /> PE SC AMOUNT I CHECK#/ RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# <br /> CODES INFO REMITTED CASH <br /> 2 �5 <br /> (0/):5/00 <br />