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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 1 ,N� 304 E-WEBFR AVE., STOCKTON CA 9520-2 (209)4b8-3420 <br /> �n1•• NON-REFUNDABLiT EXPIRES I YEAR FROM DATE SUED <br /> JOAADDRESS - Q <br /> )4"1 O <br /> 9 Fyn <br /> PARCEL SEMAPN G _ _CITYIZ��F 1O �� ��� <br /> OWNER NAME ADDRESS__`�r <br /> CITY/ZIP—_ ., _ PHONE__ <br /> CONTRACTOR _G_( ADDRESS_01_ (� I <br /> CIT'Y17.1P <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y__TOWNSHIP_ RANGE� SECTION <br /> TYPE OF WELL: ❑ NEW WFi-I. ❑ REPI..ACEhiENT R'ELL ❑ MONITORING WELL#,. _O OTHER_ <br /> INSTALLATION: WELL SYSTEM REPAIR ❑C.ROS4-'ONNECT REPAIR ❑VAPOR EXTRACTION WELL <br /> ! r <br /> TYPE OF PUMP: ❑ NEW I&EPAIR H.P. � _ DEPTH PUMP SRT!�G�_I!'. FIR>T l+l',ATER LEVEL <br /> i <br /> ❑OUT-OF-SERVICE.WELL ❑GEOTECHNICAI.M ❑SOIL BORING _ ❑DESTRL'CTiON: <br /> INTENDED USE: TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSMAi. ❑OPEN BOTTOM WELL.EXCAVATION IAA CONDUCTOR CASING DIA <br /> DOMESTIC PRIVATE ❑GRAVEL PACKISIZF, WELT, CASING TYTE WELL CASING DIA-___ <br /> O PUBLIC/MUNICIPAL ❑DRIVHN GROAT SEAL DfiPTH SPECIFICATION_ <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAvIE_ _ <br /> O MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE APPROXIMATE WELL DEPTH, CONCR IE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> f <br /> �y� _ <br /> PROPOSED CONSTRUCTION/DRIL LING METHOD: MUD ROTARY AIR ROTARY AUGUR CABLE. OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND'I HAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN (o�� <br /> JOAQUIN COUNTY ORDIANCFS,STATE S,A RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: — - - <br /> TITLE: {�I��J _ --DATE-. <br /> y — <br /> Y- L. <br /> i <br /> -1 <br /> 4Y,. <br /> DEPARTMENT USF:ONLY '*6$9 <br /> Application Accepted tly_ _ Date — / C area�� <br /> Grunt Inspection By Date— _Rimp1nspecttd Joa <br /> Desttvction Inspection By__ _ Date <br /> COMMENTS: <br /> PE SC AMOUNT CHECK RECEIVED DATE PRRMIT/SERVICE REQUEST# WELL ID# <br /> CODFS INFO REMITTED SH BY _ <br /> ���90 ©uu o ,-tom ` D S�E'Op3�S9� <br />