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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUN'T'Y PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 ^�`NON-REFUNDABLE <br /> I PERMIT EXPIRES I YEAR FROM DATE ISSUED 2 — G U <br /> JOB ADDRESS_ O2'J 3 2 4Sgl (,( C T I <br /> �f /J i <br /> PARCEL SIZFIAPN T !¢-C► e ITYr.LIP 1 <br /> OWNER N 'G .c A&o aPk DRESS /� PAYMENT <br /> CIPYlZIP I /PHONE [�9X R <br /> CONTRACTOR f !LS 14 I 1 DDRESS�«I Nov s 2OO� <br /> CiCYRIP S PHONFc�I_22--1 J��O SAN JOAOUIN COUNT' <br /> PUBLI ST�t�iciS <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP_ RANGE_SECTION <br /> TYPE OF WELL:XNEW WELL ❑ 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 FP. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DI <br /> �r <br /> *MESTIC PRIVATEGRAVEL PACK/SIZE WELL CASING TYPE_ C WELL CASING DIA <br /> ❑PUBLICIMUNICIPAL V❑DRIVEN GROUT SEAL DEPTH SPECIR ATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME _CI. <br /> 24 VAR NOTICE ,� <br /> 13 -!F <br /> MONITORING R E C�l_ _S T E C) GROUT SEAL PUMPED: /f 6 ONO <br /> ❑CHRISTY BOX ❑STOVE PIPE F <�R ALL CONCRETE PEDESTAL BY DRILLER: '"'❑YES (¢I 10 <br /> APPROXIMATE WELL DEPTH <br /> -�--ICDNS \� <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARYXAIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT i HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDIIANCES,,STAATTEE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: clGC%�WGCJ( / <br /> TITLE: DATE: <br /> V' <br /> I <br /> — — _ DEPARn T�M�EN�T JJSSONLY <br /> SE r �l ` <br /> Application Accepted By Date L OV Area I�f <br /> --- <br /> c <br /> Grout Inspection By Date�mP Inspected By Date <br /> Destruction Inspection By Date <br /> CO ENTS: (fib 1'3, 000_ S <br /> �z <br /> PE SC AMOUNT HEC RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# <br /> CODES INFO REMITTED CASH BY <br />