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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 <br /> 3SI GC CITY2rP <br /> PARCEL SIZFJE/APN <br /> OWNER NAME ADDRESS <br /> CTY/ZIP � ���,PHONE <br /> CONTRA <br /> ADDRESS Dr CI' 4-4 ( 0p c5 2 a -I <br /> CITY/ZIP ' / <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: OC NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER qq <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑� Cqq II;_ a <br /> TYPE d � 1... �� <br /> OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET rF r. FIRST WATER L <br /> w-,w,n+.f may have exPrebv%triout <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ' i eDri ' <br /> vvniil}'•i i�i� UIimsperAed <br /> INTENDED USE TYPE OF WELL CONSTRU TION AT Health a i\ r a G D I� <br /> � 19 t_= <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA 19" CONDUCTOR CASING DIA 1 // <br /> ❑DOMESTIC PRIVATE AGRAVEL PACK/SIZE 1O WELL CASING TYPE —0,C WELL CASING DIA <br /> 0 PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH S'C) (--'r SPECMCATIONZ0A,1U f TYE- � y <br /> XIRMGATION/AG 24 "R N Q'TI G E OTHER GROUT BRAND NAME �� s ct C- <br /> RI�QU ESTEC� <br /> ❑MONITORING F(D R ALL GROUT SEAL PUMPED: 13NO <br /> ❑CHRISTY BOX ❑STOVE PWN S P E CST I C)N S CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPTH <br /> '.S0 r-- <br /> PROPOSED <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY _AUGER CABLE OTHER <br /> 4 <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: r/ <br /> TITLE: ®t-A..;/'II DATE: <br /> a <br /> jjjj!�j 111!111111 <br /> h � <br /> DEPARTMENT USE ONLY <br /> i L6 <br /> Application Accepted By - - (�C.�� _ - — Date t © Area <br /> Grout Inspection By Date Pump Inspected By Date <br /> Destruction Inspection By Date <br /> COMMENTS: ma <br /> f--.j Esc <br /> PE SC AMOUNT _CHECK#/ RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# <br /> CODES INFO REMITTED CASH BY <br /> 43. $Z7�5-00 .� I a D .R-00 L-t o So <br />