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SfAT1= <br /> DF ,;�VELL/PUMP PERMIT <br /> D� SAN JOAQUIN COUNTY PkI3I"TC HEALTH SERVICES ENVIRONMENTAL HEALTH DI O <br /> 3 f� 344 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 4q�C ��� <br /> NON-REFUND BLE P`ERRIIT EXPIRES 1 YEAR FROM DATE ISSUED n <br /> JOB ADDRESS -.2- Aw CY 'alvel `%a <br /> s� 1P }� <br /> PARCEL 51ZFJAP^3 eA C CI'TY/Z <br /> // y} JJ-I1 ` <br /> OWNER NAME/g a nJ 1't t;el aw.- k SC/i t,tDDRESS A 0X � Pt16+lr,tIE.4LT tiALIH U1�°5'piv <br /> �r�,{}E;4dif,EN <br /> CITYIZIP fl G,4)6(C C, PHONE ^g'!2 <br /> r+2 – d _e), r7 S_ <br /> CONTRACTOR�Jq ez[,1 . 0-i S a)Ty _ DDRESS ?%ea(D (.6�: C Cx X +a <br /> CITYIZIP "o C T� `�!►� / PHO NF a-C7 `/' I" 2 10 <br /> 1 <br /> GEOGRAPHICAL INFORMATION- COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: R NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# _❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELT.A <br /> TYPE OF PUMP: iP NEW ❑REPAIR H.P. �9 0 DEPTH PUMP SET FT. FIRST WATER LEVEL it <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING L]DESTRUCTION-. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA /�y_ CONDUCTOR CASING DIA <br /> ❑DOMES"T"IC PRIVATE AN GRAVEL PACK/SIZE WELL CASING TYPE / WELL CASING DIA <br /> ❑PUBLICIMUNICIPAL ❑DRIV:N GROUT SEAL DEPTH SPECIFICATION <br /> IRRIGATION/AG 214 F-47-3 ���If� 07 HER GROUT BRAND DAME <br /> ❑MONITORING C11 l_j r=SE FD GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE r{ '��—�. CONCRETE PEDESTAL BY DRILLER: ❑YES NO <br /> APPROXIMATE WELL DEPTH <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 ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: t-�~ <br /> TITLE: DATE: '3 <br /> I <br /> I <br /> .ct -i <br /> W i <br /> 'Jim <br /> i <br /> i <br /> - <br /> V _ <br /> -D PARTMENT USE ONLY <br /> Application Acceptcd By Date <br /> Grout Inspection B}' Date�f `� ump Inspccced EI?�/ }�– Date <br /> Destruction Inspection Date <br /> //-1 o- J`7 s+�c racr� f b <br /> COMMENTS: L ' _!], -I' r / rr r Ur <br /> �. <br /> PESC AMOUNT HECKW ECEIVED DATE PFRMIT/S VICE REQUES WELL ID' <br /> CODES INFO REMITTED BY <br /> "hu <br /> _ � <br />