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ovia <br /> �- Jkl WELL/PUMP PERMIT <br /> 4Q S OAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE-, STOCKTONCA95202 (209)468-3420 <br /> iq�� NON-REFUNDABLE PERMIT XPIRES 1 YEAR FROM DATE ISSU/E�D`� <br /> JOB ADDRESS 4'/'[�" /� �I�I�QI 1~ �j lJ,� I� �� <br /> PARCELSIMAP/N� CJ f V AC_ CITY2SP Lrf..�.Jt� " <br /> OWNERNAME IVnIQN� �ILI�h`C 1 ADDRESS Wh <br /> [15 k <br /> �} <br /> CTI'Y�IIP PHONE ` v' "E__ 'L 15 0 <br /> CONTRACTORY GROSS �Id1JADDRESS 01 <br /> CITYlLIPC.1 / �`/IA�` <br /> 'PHONE_ <br /> 17Z <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP_ RANGE_SECTION <br /> TYPE OF WELL: ❑ NEW WELL b REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ADESTRUCI'ION: �`V <br /> rf <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLIGMUNICIPAL ❑DRTVFN GROUTSEALDEPTH SPECIFICATION <br /> ❑1RRIGATIONlAG 24 HR NOT I(—_R'HER GROUT BRAND NAME <br /> REc�UESTE� <br /> 11 MONITORINGF C—)R A L L GROUT SEAL PUMPED: 13 YES ❑NO <br /> ❑CHRIS'TY BOX ❑STOVE PIPE I N S P E CTI O N SONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED TINS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> IOAQUIN COUNTY OOR,DDIANCFSS,,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: <br /> TITLE: DATE: <br /> 07 <br /> 1 <br /> USE ONLY <br /> Application Accepted By `^ s��1�^'� DateA QAQ�1 T <br /> gECEfVED <br /> Grout Inspection By Date Pump Inspected By Daate ���,✓.�5}�{ <br /> Destructr2 I1 r l. -% Y l ion Inspection B ��--2� __ _ Date 00 <br /> COMMENTS: <br /> PUBLIG HEALTH SfR'e7Ct4 <br /> — _ cmunnNn=•.t:..u:elnI nitaS:Oh <br /> PE SC AMOUNT C RECEIVED DATE PERMITISERVICE REQUEST# WELL ID# <br /> CODES INFO REM=D ASH BY <br /> 1 q 46T? t.6 �� 9r<oo a 9 c�Po 0 ZX <br />