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WELL/PUMP PEIMT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304EWEBERAVE., STOCKTONCA95202 (209)468-3420 PUMP <br /> NON-REFUNDABLE PERMIT E 1 YEAR FROM DATE ISSUED <br /> t J� <br /> JOB ADDRESS <br /> PARCELSi APN <br /> OWNER NAME ADDRESS <br /> CITY PHONE <br /> CONTRACTO —ADDRESSY <br /> CITY/Z1P��,. ✓ y 71 - -PHONE--y <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y_TOWNSHIP_ RANGE—SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL N O OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS ONNECT REPAIR ❑VAPOR EXTRACTION WELL N <br /> TYPE OF PUMP: ❑NEW IXREPAIR H.P. DEPTH PUMP SET LI FT. FIRST WATER LEVEL � <br /> ❑OUT-0F-SERVICE WELL ❑GEOTECHNICAL N ❑SOD.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/S(ZE WELL CASING TYPE WELLCASTNG DIA <br /> O PUBLJCMUNICIPAL ❑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 O NO <br /> L_ <br /> APPROXIMATE WELL DEP-1'H c 4 I <br /> PROPOSED CONSTRUCTION/DRILLING,METHOD: MUD ROTARY_AIR ROTARY_AUGER_CABLE_OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS YPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDI CES,STATE L S. ULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: <br /> — <br /> TITLE: DATE: I <br /> C <br /> t <br /> 1 <br /> i <br /> r <br /> i <br /> — - ——— _ EPA T USE ONLY v/�// /J <br /> Application Accepted By f, Da <br /> /te /�v <br /> Grout Inspection By Date Pump Inspected Ji,— Date <br /> J <br /> Desuuction Inspection By _ /Date <br /> COMMENTS: <br /> PE SC AMOUNT CHEC RECEIVED DATE PERMIT/SERVICEREQUESTN WELL IDN <br /> CODES INFO REMITTED ASH BY <br /> 4 ago OSO So, Jo 3 o Sp-00a 53 3 <br />