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J <br /> r <br /> WELL/PUMP PERMIT z <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTALHEALTH DI SIO <br /> 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 YM ENT <br /> EIVED <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS 211,70 C <br /> r.adgf A 60(✓ <br /> PARCEL SIZE/APN CITY/ZIP <br /> � PUBLIC HE S <br /> OWNER NAMF�OL/.�iY oF Siw/ IAQb �gsME10 — t2E Liv� ENVINTAVREALTH <br /> DIVISION <br /> CITY/ZIP �F�l /L%p.✓ PHONE <br /> CONTRACTOR 404 a Cg F_ Z/DE!C4&rgL,6MRESS 46<3 45;; f E.✓/'S G A '0't <br /> CITY/ZIP AC L <�!4 d". 9.Z 1:29 PHONE gj29 <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ' 13 OTHER 9AX tIlIC4 <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR RNAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR 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 <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA 1 , CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE h'O�°E WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING 24 HIR IV C:)-Fl cadEr SEAL PUMPED: ❑YES ❑NO <br /> [3REc�uES-rE CHRISTY BOX ❑STOVE PIPE FC)R A L L CRETE PEDESTAL BY DRILLER: OYES ❑NO <br /> APPROXIMATE WELL DEPTH ,"S F;"E G"T"i(I N S <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 ORDIAN�CpES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: <br /> TITLE:_. L/:cy A Ew/r DATE: <br /> A4 CA <br /> E <br /> #1...........I <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Y Date Area <br /> Grout Inspection By Date Pump Inspected By Date <br /> Destruction Inspection By Date <br /> COMMENTS: I o Q R/1'L leo14,v0 AOM&&!(,L ;Z-2`01 • .51126 01511- X964 04WU< A992*— dAE.W _ <br /> 1,AR13dikk <br /> PEAMOUNT (:CHECW RECEIVED DATE E IT/SERVICE REQUEST# WELL ID# <br /> CODES INF <br /> O REMITTED SH BY <br /> (off t5"� 2�0•°O � � L- �°/ �L <br />