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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DACE ISSUED <br /> JOB ADDRESS 57 71 A Lny aLi L — <br /> PARCFL SIZE/APCN L C <br /> ITY/ZIP r <br /> OWNER NAME Jct t� tel°`ri G[ K��� � <br /> CITY/ZIP 4'- i a lq S_�ile2-. PHONE <br /> CONTRACTOR `c7 i�/�� rj .ibr ADDRESS ?JM S�,r <br /> CITY/ZIP �� —PHONE <br /> GEOGRAPHICAL <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE;OF WELL: X NEW WELL ❑ REPLACEMENT WELL EI MONITORING WELL# _❑OTHER <br /> INSTALLATION: 13 WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL;0 <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑C:EOTECHN[CAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> Fr <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DiAI I CONDUCTOR CASING DIA <br /> DOMESTIC PRIVATE Pl�-IRAVEL PACK/SiZE tC I WELL CASING TYPE <br /> /__ <br /> 1"11C-- WELL CASING DIA -f� <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH i" SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME I` 67 J r! <br /> ❑MONITORING GROUT$FAL PUMPED: RYES ❑NO <br /> ❑CHRISTY BOX ❑STOVEPIPE CONCRETE PEDESTAL 13Y DRILLER: ❑YES )NO <br /> APPROXIMATE WELL DEPTH ;Lm <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR 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 CR DIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: <br /> TITLE:. DATE: <br /> LF <br /> I � <br /> All <br /> e k <br /> M... <br /> fEP TMEN U E ONLY �y /l <br /> Application Accepter.By wA Date 15 ` 0 V Area <br /> Grout Inspection Fsy Date -Rump Inspccced By Date. <br /> Destruction Inspection By Date <br /> COMMENTS: 10 y <br /> PE SC AMOUNT C RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# <br /> CODES INFO REMITTF,D CASH BY <br />