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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 3 ji-GEIS <br /> 304 E_WEBER AVE., STOCKTON CA 95202 (209)408-3420 <br /> I r, NON-REFUNDDABLE PEIT 17S I YEAR FROM DATE ISSUED <br /> IOB ADDRRSS ° U D EI r A 417e — <br /> PARCEL SIZE/APN Q CITYMP '5 L Sk <br /> OWNER NAME A KC IMI i fdk I I ADDRESS e <br /> CITY/ZIP PHONE Za, <br /> CONTRACTOR-_ �O' �f�'�- ADDRESS L � <br /> C1TY/ZIP .Q �2"N / J IR� PHONE. <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WE4's j <br /> TYPE OF PUMP: ❑ NEW REPAIR H.P. Ir DEPTH PUMP SET Fr. FIRST WATER LEVEL ! <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL.BORING ❑DESTRUCTION: <br /> INTENDED USE 'TYPE OF WEI,1, CONSTRUCTION SPECIFICATT N <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ;RDOMESTIC PRIVATE ❑GRAVEL PACKISIZE WELL CASING TYPE WELL CASING DIA_ <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE,PIPE Q CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPTHt/ <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TILE WORT{WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COU TY ORDIANCES, TATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: <br /> TITLE: DAITr: <br /> �f <br /> I N <br /> I =� � ISESVI <br /> - <br /> i <br /> 01 <br /> i I <br /> DEPARTMENT USE ONLY <br /> J <br /> Application Accepter:By a O+—D — D, 4rea <br /> Grout Inspection By v_- Date Pump Inspected u.11 S <br /> Destruction Inspection By Date <br /> COMMENTS: <br /> PE SC AMOUNT CIIECKtV RECEIVED DATE PERMITfSERVICF REQUEST# WELL ID# <br /> CODES INFO REMITTED H BY <br /> 3�o DSD $10-- Zz'c) _ l 6P00 3,2 (o <br />