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WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 NON-REFUNDABLE I PERMIT EXPIRES I YEAR FROM DATE ISSUED 2 L4 3-l G O V /� JOB ADDRESS Oe- �t S b 0 6L T I In 1 V. / //ff , PARCEL SIMAPN p /7-CI'e�CITYIZIP I OWNER N 'L V, Ahl 11 Vt DRESS PAYMENT R CPTY/ZIP I PHONEY CONTRACTOR bG !LS I 1 DDRESS I I %VyN�S NOV 6 2000 CITYlLIP S PHONE ��—l�<4 SAN JOAQUIN COUNTY PUBLI R�Tcr v GEOGRAPHICAL INFORMATION; COORDINATES X Y TOWNSHIP RANGE SECTION TYPE OF WELL:YNEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOH.BORING ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA , CONDUCTOR CASING DI 40 MESTIC PRIVATE /JQ GRAVEL PACK/SEE WELL CASING TYPE WELL CASING DIP. ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH _ SPECIFI ATION 2-1 �� NOTICE ❑IRRIGATION/AG OTHER GROUT BRAND NAME l r&L ,�/ 1:1 MONITORING R E O t-_f F_S T E LD GROUT SEAL PUMPED: !J>ZYES ❑ O ❑CHRISTY BOX ❑STOVE PIPE F f\L L_ CONCRETE PEDESTAL BY DRILLER: 13 YES /////y��Nt APPROXIMATE WELL DEPTH TIONS PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY+AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDDIIAANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. SIGNED: TITLE: v I Ile r DATE:,,[ J - - DEPARTM_ENT SE ONLY r �l Application Accepted By Date Grout Inspection By Date#v_a2Pump Inspected By Date — Destruction Inspection By ('� DDaatee GG ENTS: (0 13_ "+-G;Nl � s(�-Uv`C��S - •:�l -�0�� s z PE SC AMOUNT HEC RECEIVED DATE PERMIT/SERViCEREQUEST# WELLID# CODES INFO REMITTED ASH BY l� L /03,50 l� �� 5�2flU�