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WELL/PUMP PERMIT <br /> _ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION �n <br /> 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPI ES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESST 0 8! f.C I'C ^@ .& a:7 <br /> PARCEL SIZE/APN U A c v-{S } CITY/ZIP_ Lod.' LA P1 AR <br /> OWNER NAME f�f S C' JAG a r'1 �� � hD ADDRESS �/�✓"Y' <br /> CITY/ZIP LrlC.0(7� f' 6A '9 & vR y O PHONE <br /> CONTRACTOR /-` UO vVt6f r%J S 14"I'(-- ADDRESS P 1:2 `/l.�s I C L�� i J FZJC / f'Ir'✓" <br /> CITY/ZIP 'yZ�c:I C ✓ �S� /, PHONE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACE ENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR R S-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑0 EN BOTTOM WELL E VATION DIA COND CTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GR VEL PACK/SIZE WELL CASI TYPE WELL CA NG DIA <br /> ❑PUBLICIMUNICIPAL ❑DRIVE GROUT SEAL DE SPECIFICAT <br /> AJIRRIGATION/AG 2 4 R N C)—Fl C F'HER GROUT BRAND NAME <br /> ❑MONITORING REQUESTED <br /> I=(DR \L L GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE I N S P E GT(C7 N 4DDNCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> /jo-1 u ( <br /> APPROXIMATE WELL DEPTH RY l ,I f`S C�+c may'{ (. /Y` <br /> i ��+rICC �N�� <br /> PROPOSED CONSTRUCUON/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 O IANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: <br /> TITLE: �t/� DATE: <br /> C <br /> li <br /> ■ <br /> I <br /> DEPARTM T USE ONLY <br /> Application Accepted By ( ( /\��-- Date v l 0C) Arca <br /> i Grout Inspection By Date PAY Date Pump Inspected By ECCI �V E n <br /> Destruction Inspection By bate <br /> COMMENTS: <br /> AN11 44PUBLIC <br /> PE SC AMOUNT CHECK#/ RECEIVED DATE PERMIT/SEMWINEQUEST# '} WELL ID# <br /> CODES INFO REMITTED BY <br />