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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISII)N <br /> 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 RECEIVED ME N�f YNYM <br /> NON•REFUNDABLe PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ]OC.4DURF.'S8 �( }{�1e,,, ,�,�(, OCT 10 2000 <br /> PARCELSIMAP�N[ � CITY2IP ^TphL.e.w cnu (AD LN CGL'NIY^ <br /> T�QM d-J1OL� 14m -.pYg- llq/,�, ENVIRLO'iMfNTR LIIl fill %IEl9li <br /> OWNF,R NAME OJ1M H'1-� ADDRESS <br /> CITY/9P t PHf1NF. -20 1 - fsa3 <br /> CONTRACtt1Ry+t�F WG.)4 Slb �, £iltdE- �DORE <br /> clnzlr lax.... 1:. �1PS iU�f PxGNE Ca-�`t) ;L <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y_ TOWNSHIP__ RANGE_ SECTION <br /> TYPEOFWELL: ❑ NEWWELL ❑ REPLACEMENTWEI-L ❑ MONITORING WELL n _❑OTHER <br /> INSTALLATION: SYSTEMREPAIR ❑CROSS-CONNECTREPAIR ❑VAPOR EXTRACTION WELL <br /> I'YPEOFPUMP: p 'EW ❑REPAIR R.P. 1 DEPTH PUMPSET - OFT, FIRST WATER LEVEL _. <br /> ❑OUT-OF-SP.RVICE`WELL ❑GiliMECHNICAL Y ❑SOILBORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA_ CONDUCTOR CASING DLL <br /> ?�// <br /> ESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TVPE . V•L � WGLL CASING DIA� <br /> !!❑PUBLIC/MUNICIPAL RI GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG REQLJ FS 14 7, OTHER GROU BRAND NAME <br /> ❑MONITORING F(D!nC AL-L_ GROUTSFALPUMPED: ❑YES CI NO <br /> I NS PEC'-J-It";P,f, <br /> ❑CHRISTY BOX ❑STOVE PIPF CONCRETE PEDESTAL BY DRILT.ER: ❑YES ❑NO <br /> APPROXIMATE WF.1.1.DEPTH O U(o PT <br /> PROrOSEDCONSTRUCTION/DRILLINGMETHOD: MUD ROTARY_AIR ROTARY-AUGER_CABLE_ OTIIER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE.WITH SAN <br /> JOAQUIN rUNTY ORIIIANCES.STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: LIY 1� O <br /> TITLE•:4 DATETO <br /> Jill III <br /> I <br /> DEPARTMENT USE:ONLY �p <br /> APPliwlion Accepmu By �. ^" �-/ { : 1• '-r �L`. Dnm _Aron /699 <br /> Gmm InsNctiun By. Dae Pump hl,da By <br /> DesLmcuon Inspection BY'' 4 Dale <br /> COMMENTS: - -1 x Z711 K 1 <br /> PE SC AMOUNT 'HE'Kk RECEIVED DATE PERMI'I'/SERVICE REQUEST C WELL]DO <br /> CODES INFO REMITTED CASH BY <br /> 1/ 9 D o y 3 ed� 1 ,Tpo a I Q <br /> d <br />