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WELL/PUMP PERMIT <br /> L <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 4 }f/ 304£.WEBER AV£., STOCKTON CA 95202 (209)4643-3420 <br /> V OlC NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED !Y <br /> .I013 ADDRESS :L[firseebbbi o t Et,7 414d 5 o ' <br /> PARCF-1.SIZFJAPN_67 T CITYIZIP q5316 <br /> OWNERN'A C!{FuRf7N Exavf DQR£SS ODi 6011r Gir bu <br /> R4o"C-ItENT cuKii�ur <br /> CITYIZiP�AD Its! 0119$6.13 PHONE C �E i16WtffP t9 5) <br /> CONTRACTOR SPEY 7+Q t:JS°1QP 7&:0 741 ADDRESS <br /> aTYfGIP _SnrkL. f 4f3 PHONE wg-V66-1713 <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP_ RANGE SECTION <br /> TYPE OF WELL: ❑ NEWWELL ❑ REPLACEMENT WELL MONITORING WELL# hEGI- i4 ❑OTHER_ <br /> � l <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECTREPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SEEP—FT. FIRST WATER LF'UEL 12 UD d <br /> ❑OUT-OF-SFRVICC WELL D GEOTECHNICAL 00 ❑SOIL BORING ADESTRUCTIC, <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIAD <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACKISTZE WELL CASING TYPE _ W£LLCASINGDIA <br /> ❑PUBLICIMUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATIONlAG OTHER GROUT BRAND NAME <br /> 1KMONITORINGs GROUT SEAL PUMPED'. ❑YES ONO <br /> NirCHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO [\ <br /> APPROXIMATE WELL DEPTH 2'4.5 F!'. —� <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTAR �_AUGER CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE W [LL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED:__ <br /> TITLE: K F-GLbe.1 57 __DATE: <br /> AT <br /> L '14 q- <br /> r <br /> AI <br /> na <br /> ir <br /> o <br /> ' mss i 1 <br /> 7 ar'. - <br /> I <br /> DEPARTMENT USE ONLY 7 <br /> Application Accepted By Dale 3-i r �G Area_ <br /> Grow Inspection By Date Pump Inspected By Dale a-? C <br /> Destruction inspeclinTiLBv_ Date <br /> COMMENTS: <br /> PE SC AMOUNT CHFCK#I RECEIVED DATr PERMITMERVIC£REQUEST# WELL 1D# <br /> CODES INFO REMITTED CASH BY <br /> Q t/ <br />