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WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION !� 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE i55UEA f JOB ADDRESS PARCEL SIZEIAPN_= / 7'�r CITY/ZIP OWNER NAME Ag _. ADDRESS n PHONE CITYIZIP ti r' f YJ CONTRACTOR P AZ 1LU A Tc�R w PILADDRESS CITYIZIP C PHONE s d OPS-7 GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION I� TYPE OF WELL: X NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER INSTALLATION: ❑WELL SYSTEM REPAIR E3 CROSS-CONNECT REPAIR 13' IIt - Ll ;Co TYPE OF PUMP: ❑ NEW II ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER L V may nave expired ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DE INTENDED USE �: TYPE OF WELL CONSTRU TION C ATI Health Dj�=;�j� t II tI The CONDUCTOR CASING DIA f a//- ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION AIA !� E_ WELL CASING DIA ❑DOMESTIC PRIVATE P �I'GRAVEL PACK/SIZE-IrWELL CASING TYP ❑PUBLIC/MUNICIPAL �l ❑DRIVEN GROUT SEAL DEPTH Q r`r SPECIFICATION('QA/C.t?'1E I, XIRRIGATION/AG 24 HR N HT1 C E OTHER GROUT BRAND NAME G I° R E Q U E ST E ED GROUT SEAL PUMPED: KYES A ❑NO Sac ❑MONITORING O R ^L_1 ❑CHRISTY BOX ❑STOVE PIP�[v S P E CT I O N S CONCRETE PEDESTAL BY DRILLER: ❑YES 13 NO ii 5. D + f� APPROXIMATE WELL DEPTH PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN J O IA S,ST L S SAN TI SOF N NC N y nz NED: DA C3 a y 02 4 t DEPARTMENT USE ONLY _ Date� T 761Area F � - Application Accepted By Groat Inspection By Ii Date Pump Inspected By Date s I' Date Destruction Inspectti�on By COMMENTS: ,Y it PE SC AMOUNT CHECK#1� RECEIVED DATE PERMITISERVICE REQUEST# WELL H3# CODES INFO REMI71'17ED CASH BY y3.6 l ao �Zzs 0 g�f ' I!° DS 9-M 0 ii ..