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FILE COPY <br /> WELL/PUMP PERMIT <br /> SANJOAQUIN COUNTY PUBLICIICALTII SERVIC85 ENVIRONMENTAL I IE ALM DI VISION -IV <br /> JME WCtl.R AVE.. STOCK M.CA 95:11: RINJI JfiS-JJ311 <br /> NON-REFUNDARLE PERM IT EXPIRES I YEAR FROM DATE.ISSUED ✓ q/`f'/ /.• <br /> JOBADDRESSJ ! A WWOW qf 4"d Scoaua a_ I_ J <br /> PARCEL SIZFIAPN , G ' ciTY2IP <br /> OWNER NAh CNEURON E ROU •`�ABDRFSS 001 <br /> COBOLI' o <br /> S <br /> NRARCRYRIP SAM : 8HAYy�PIONE TAT f NOw ,P L92,7 s64e2 �• <br /> CONTRACTOR 5Jte7O?IW &eIAPAThU ELe. ADDRESS 28Ab IF /LY^1/ SI f <br /> CrtY2IP 51 kEee190oC PHONE xo9-Y6s-9Tl] <br /> GEOGRAPHICAL INFORMATION:COORDINATES X_ S'_TOWNSHIP RANGE_SECTION__ <br /> TYPEOF\YELL: ❑ NEWWELL ❑ REPLACEMENTWELL M MONITORING WELL N AO/-19 ❑OTHER <br /> INSTALLATION: DWELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOREXTRACTIONWCLLM p <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR II.P. DEPIII PUMP SET FT. FIRSTWATERLEVCL • TSD r. <br /> ❑OU-OF-SERVICE WELL ❑GCOTECHNICALM ❑SOILBORING ADESTRUCDON: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECT FICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELLEXCAVATIONDIA_ CONDUCTOR CASING DIA_ <br /> ❑DOMESTICPRIVATC ❑GRAVEL PACKISIZJ3_ WELL CASINGTYPE WELL CASING DIA <br /> ❑PUBLICIMUNICIPAL ❑DRIVEN GROUTSEALDEFTH SPECIFICATION <br /> ❑IRRIGATIONIAG OTHER GROUT BRAND NAME <br /> I(MONITORING GROUT SEAL PUMPCO: DYES ONO <br /> L7CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES 0 N <br /> APPROXIMATE WELL DEPTH 13 5 Ff <br /> PROPOSED CONSTRUCOONIDRILLINGMETHOD:MUDROTARY_AIR ROTAR �AIGERCABLE_OTHER_ <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TD: NE IN ACCORDANCE WITIISAN <br /> JOAQUIN COON <br /> FY ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN C'OUNT'Y. <br /> SIGNED: / <br /> TITLE: ZS FGc!•Z•57 DATE: �•^=>(+ J�/Y}rPYI <br /> ry <br /> a2-x r <br /> m-,y— J <br /> „,I..in0 <br /> DEPARTMENT USE ONLY /// <br /> Applin,iun A¢vpiN RY DaN 3-17-de A.-Ad <br /> ll <br /> Gnw,lmpeCllun DY Dan: Pomp lnspN cd BY Dm <br /> Desrunion l,sspeni Y /,,/RT//1 9 Da,e 3— 'X'7—� <br /> COMMENTS: /ty �A/-aYq�f ?P- — �7- 6�i 3 y7 U <br /> PE SC AMOUNT CDECKV RECEIVED DAT- PERMIT5ERVICE REQUEST N 71� WELLID. <br /> CODES INFO REMITTED CASH BY <br /> O lw <br />