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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 XPIRES i YEAR FROM DATE ISSUED <br />JOB ADDRESSyt�VA61QL-' �(' L 006 � fig /D C-16 SCj4V0C <br />PARCEL SIZE/APNCITY/ZIP 7 XAC-Y eA <br />OWNERNAME�i Y ADDRESS ice, - %1 s <br />CITY/ZIP / xMMly PHONE c f'.4 - S-03Z_ <br />CONTRACTORyPt L��/� ADDRESS 23 (/ S w/a�� 4 ��� <br />�-S / <br />CITY/ZIP V C�e 7-21PHONE 4S" -,F 71 Z- S l 2 Z <br />GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br />TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL # XOTHER <br />INSTALLATION: ❑ WELL SYSTEM REPAIR ❑ CROSS` -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # <br />NFAP' b� I?4A R C..` Ci 6� (� <br />TYPE OF PUMP: ❑ ❑ I 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 �� n <br />INDUSTRIAL ❑ OPEN BOTTOM WELL EXCAVATION DIA / CONDUCTOR CASING I <br />❑ DOMESTIC PRIVATE ❑ GRAVEL PACK/SIZE WELL CASING TYPE WELL CASING DIA <br />❑ PUBLIC/MUNICIPAL ❑ DRIVEN GROUT SEAL DEPTH SPECIFICATION <br />❑ IRRIGATION/AG 24 HR N OTI CffER GROUT BRAND NAME <br />MONITORING R E Q U E S -FE GROUT SEAL PUMPED: ❑ YES ❑ NO <br />❑ CHRISTY BOX ❑ STOVE PIPE FOR ALL CONCRETE PEDESTAL BY DRILLER: ❑ YES ❑ NO <br />IN ECTIONS� <br />PPROXIMATE WELL DEPTH <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER�y <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDIANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />SIGNED: d ` 5` ` <br />TITLE:DATE: <br />DEPARTMENT USE ONLY <br />Application Accepted By Date / J ©O Area <br />Grout Inspection By Date Pump Inspected By Date <br />Destruction Inspection By Date 0.6 <br />/ <br />COMMENTS: <br />PE <br />SC <br />AMOUNT <br />CHEC / <br />RECEIVED <br />DATE P T# <br />WELL ID# <br />CODES <br />INFO <br />REMITTED <br />CAS11 <br />BY <br />6' o <br />