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!L WELL/PUMP PERMIT <br /> SAN JOAQ�IN COUNTY <br /> 04 N PUBLIC <br /> R �S20�9N48���DIVI <br /> WEEAVE�TO<KTONCA9520 (20VVELL <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> 36 T/, H <br /> F,O,ADDRESSI:) -- <br /> PARCEL SIZF/APN _// CITY/ZIP /J <br /> OWNERNAME�*q /I <br /> f V--m_4.. D / <br /> urr{ ADDRESS._I X 11 3� �G� <br /> CITY/L1P &,cG PHONE <br /> CONTRACTORCCS &W-a —e P[�Ir�_ADDRESS <br /> CITY/LIP, 4SJ rO PHONE IO ! _ , <br /> GEOGRAPHICAL INFORMATION:COORDINATES X Y_TOWNSH]P_ RANGE_SECTION <br /> TYPE OF WELL: ❑ NEW WELL <br /> X�REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTSON WELL# <br /> TYPE OF PUMP: ❑ NEW E3 REPAIR H.P. <br /> DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑OUTAF-SERVICE WELL <br /> ❑GEOTECHNICAL# ❑SOIL BORING XPESTRUCTION: <br /> D U / / <br /> lXff OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA L!,CONDUCTOR CASING DIA <br /> — <br /> 0 `,�- WELL CASING DIA_/!_ <br /> AOMESTICPRIVATEARAVELPACK/SIZE�I'� WELL CASINGTYPE� <br /> CI PUBLIC/MUNICIPAL <br /> [3 DRIVEN GROUT SEAL DEP H 1� SPECB'ICATIOI}� <br /> ❑IRRIGATION/AG 2,4 H R <br /> OTHER GROUT BRAND NAME <br /> R E Q U E ST E C> GROUT SEAL PUMPED: XyES (3NO <br /> E3 MONITORING Fa n ^A— <br /> [3CHRISTY BOX ❑STOVE PIPF.�NSP -T-,�NS CONISLCRETE PEDESTAL BY DRILLER: ❑YESJ10 <br /> APPROXIMATE WELLDEPTH V <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 UV ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY RDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> PAYMENT <br /> SIGNED: <br /> DATE:_ <br /> TITLE: <br /> IT T <br /> 0 <br /> 61 <br /> i <br /> DEPARTMENT USE ONLY <br /> � �� Date <br /> Application Accepted By 7 �/J� <br /> D te /• RuMp Inspected By Daze <br /> Grout Inspection By /L 7� <br /> Due <br /> Destruction Inspection By <br /> COMMENTS: � j� <br /> 'IVc/. T WELL ID# <br /> � <br /> ' _PE SC AMOUNT CHECK#/ RECEIVED DATE _ <br /> CODES INFO REMITTED CASH Y <br /> 3 <br />