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WELL/PUMP PERMIT ' SAN JOAQUII�UNTY PUBLIC HEALTH SERVICES ENVIRONMErh�HEALTH DIVISION X04 E.WEBER AVE., STOCKTON CA 95202 (209)46$-3420 1 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS S f [�� r►1' W f Z PARCEL SIZE/APN N 15,3G , CITY/ZIP 01C S 2-s-3 OWNNER P t p �A�I d�OSQi Ut'!/tPLtGt ADDRESS P' 0• �O Zq` $ CITY/ P v !Gtr~ S ZS PHONE O r 3 3 ! 0 / 02- ,q CONTRACTORS q? 10a4 an - C-' ADDRESS Z CP 5 w0w a v-n D rr`v CITY/ZIP S+'ocA_,+"� CA q52-06- PRONE 28 - Cv 5 ~ 8 �/2 " ``7 � GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP 3 RANGE_'�' SECTIONAgM� TYPE OF WELL: 0 NEW WELL C] REPLACEMENT WELL 11 MONITORING WELL# �OTHER�U d 65 f��I S INSTALLAT^O ❑WELL SYSTEM REPAIR 13 CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# tlk TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL NIA Q OUT-OF-SERVICE WELL ❑GEOTECHNICAL# SOIL BORING 7'lbb 10R ❑DESTRUCTION: INTENDED USE TYPE OF WELI. of h CONSTRUCTION SPECIFICATION ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELL CASING DIA *PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH ZO SPECIFICATION g � Pq *IRRIGATIONJAG OTHER GROUT BRAND NAME %MONITORING fn MT-OF t%n -Qit rI/y GROUT SEAL PUMPED: 0 YES I�NO 1'ZW� El CHRISTY BOXY ©STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES )4 NO APPROXIMATE WELL DEPTH ZOe G�1� V`UZ.F- PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AU��TER�CABLE OTHER �plfObJ � I I HEREBY CERTIFY THAT I HAVE PREPARED TRIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE W JOAQUIN COUNTY ORRDIIA-N-C�ES,STATE/LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. SIGNED: tGl c • 4 TITLE: r�ha DATE: I L1 DEPARTMENT USE ONLY Application Accepted By. Date113/0 _Area Grout Inspection By Date ump Inspected Sy Date Destruction Inspection By Date COMMENTS: PE SC AMOUNT CHECK#/ RECEIVED DATE PFR.MIT/SERVICE REQUEST# WELL ID# CODES INFO REMITTED CASH BY i0Oar t �.