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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 1 YEAR FROM DATE ISSUED <br />JOB ADDRESS // ep MZ-40k) "fre. <br />PARCEL SIZE/APN /39 - e, 2-0- 03 CITY/ZIP 57-0e-IV--IT2A/ <br />OWNER NAME /hi-e, /144b5/4*641/41 ADDRESS j17- 40- c:)-1- 575— <br />r5W-S PHONE .. <br />CITY/ZIP .., _57aese-704/ r4 <br />CONTRACTOR W"e-S* 7.--,4it0/0,17- ADDRESS 3? Kg F2 -7-7-6,Kiiefe-L) <br />CITY/ZIP5redeP0144/70 49,-- '67(./2. PHONE (iPte9 e 725 - 7Z 76 I / <br />GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION c <br />c <br />WELL: 0 NEW WELL 0 REPLACEMENT WELL )3C MONITORING WELL # / G4/041.- 0 OTHER TYPE OF <br />0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL # I INSTALLATION: 1 <br />0 NEW 0 REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 1 TYPE OF PUMP: <br />I <br />WELL 0 GEOTECHNICAL # 0 SOIL BORING 0 DESTRUCTION: 0 OUT-OF-SERVICE <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br />crit <br />0 OPEN BOTTOM WELL EXCAVATION DIA v CONDUCTOR CASING DIA 4/4- 0 INDUSTRIAL <br />0 GRAVEL PACK/SIZE WELL CASING TYPE /Pile" WELL CASING DIA G.-- El DOMESTIC PRIVATE / e <br />0 DRIVEN GROUT SEAL DEPTH AO SPECIFICATION A/RT-C-e4V444 <br />0 PUBLIC/MUNICIPAL <br />OTHER GROUT BRAND NAME 0 IRRIGATION/AG <br />)(MONITORING GROUT SEAL PUMPED: 0 YES <NO <br />KCHRISTY BOX 0 STOVE PIPE CONCRETE PEDESTAL BY DRILLER: 0 YES Ar NO <br />t <br />APPROXIMATE WELL DEPTH 422 <br />MUD ROTARY AIR ROTARY AUGER e CABLE OTHER PROPOSED CONSTRUCTION/DRILLING METHOD: _ <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:tr:;f r <br />'43 /'). i/V7 75 r - DATE: 3# / ('ZI TITLE: //6 / / <br />1 _ <br />M111111111 I <br />DEPARTMENT USE ONLY <br />Application Accepted By ‘1...A.,An..A ryl..4.-1,-^,. Date Area <br />Inspection By Date If, Pump Inspected By Grout Date <br />Destruction Inspection By Date <br />COMMENTS: <br />PE SC AMOUNT CHECK#/ RECEIVED DATE PERMIT/SERVI E UEST # WELL ID# <br />CODES INFO REMITTED CASH BY <br />35-c I cei.co (c --)- 0 tj <br />_-----