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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 DATE ISSUED <br />JOB ADDRESS /!�� / � fi_+ A4e 'Qlw 9 Sti E <br />PARCEL SIZE/APN�%%��tif%— CITY/ZIP <br />Of'/!S7z%9:W 40OZ /�� G�+7�?ba 57-. <br />OWNER NAME( .'V ADDRESS ,/� <br />CITY/ZIP`PHONE <br />j^ 3233 TzGz� <br />CONTRACTO'R�� /6 f ADDRESS <br />f �/� f�7LPHONE /9/6% 639 -7z 7 G <br />CITY/ZIP 7,% <br />GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /># <br />TYPE OF WELL: C NEW WELL ❑ REPLACEMENT WELL MONITORING WELL5 ❑ 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 ❑ DESTRUCTION: <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br />Q r� <br />CASING DIA <br />❑ INDUSTRIAL ❑ OPEN BOTTOM WELL EXCAVATION DIACONDUCTOR <br />j'O <br />❑ DOMESTIC PRIVATEiRAVEL PACK/SIZE WELL CASING TYPE/C WELL CASING DIA Zr/ <br />f <br />❑ PUBLIC/MUNICIPAL ❑ DRIVENGROUT SEAL DEPTH b_ SPECIFICATION <br />❑ IRRIGATION/AG OTHER GROUT BRAND NAME <br />MONITORING GROUT SEAL PUMPED: ❑ YES NNO <br />ACHRISTY BOX ❑ STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑ YES ANO <br />APPROXIMATE WELL DEPTH 7� <br />PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER X 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 ORD ANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />SIGNED: l <br />,! <br />/'�F�T �r5T DATE: -- -- <br />TITLE: <br />DEPARTMENT USE ONLY <br />Application Accepted By�i��/�M G V� Date I dc IArea <br />Grout Inspection By 1 AXE DatePump Inspected By Date <br />Destruction Inspection By Date <br />COMMENTS: <br />PE <br />SC <br />AMOUNT <br />CHECK#/ <br />RECEIVED <br />DATE PERMIT/SERVICE REQUEST # WELL ID# <br />CODES <br />INFO <br />REMITTED <br />CASH <br />BY <br />5R. U0 A����S <br />ll <br />0oa <br />9 <br />N <br />1� <br />