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u WELL/PUMP PERMIT' <br /> ' W 't SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 <br /> GD�y NON-REFUNDABLE PERMIT XPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS / '�/pL v <br /> PARCEL SIZFJAPN CITY2nIP I /`'7` ch CFS <br /> OWNER NAME�1 • U/VI A/ SCFFa a ADDltEss sT' .�1 J <br /> CITY/ZZIP PHONE zo �3 I S-v3 Z <br /> CONTRACTOR .r�' tt67*UM ._ADDRESS Z 3 (0 S 4✓/4 x.4101 a/2 �s"7 <br /> CITYlZp SM HONE 71 Z <br /> GEOGRAPHICAL INFORMATION; COORDINATES X-- Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: 0 NEW WELL . 0 REPLACEMENT WELL 0 MONITORING WELL <br /> INSTALLATION: 0 WELL SYSTEM REPAIR 1 13 CROSS--CONNECT REPAIR 13 VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: 0 NEAP'07-13 AIIi`H.P DEPTH PUMP SET Fr, FIRST WATER LEVEL <br /> 0 OUT-0F-SERVICE WELL O GEOTECHNICAL# Cl SOIL BORING Cl DESTRUCTION: <br /> INTENDED USE TYPE OF WELL90BRUCTIONSMIE[CAln <br /> ??120ef- <br /> 0 INDUSTRIAL O OPEN BOTTOM WELL EXCAVATION DIA ri( CONDUCTOR CASING DIA <br /> C]DomrsnC PRIVATE 0 GRAVEL PACK/SiZE WELL CASING TYPE WELL CASING DIA <br /> 0 PUBLICIMUNICIPAL 0 DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> O IRRIGATION/AG 24 HR N OTI CSR GROUT BRAND NAME <br /> )eMONITORING R E Q U E STE E MOUT SEAL PUMPED: 0 YES 0 NO <br /> 0 CHRISTY BOX 0 STOVE PIPE 1=a R A!"I_ <br /> S�ONCRETE PEDESTAL BY DRILLER: OYES D NO <br /> ECTION <br /> IN <br /> APPROXIMATE WELL DEPTH + <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHERS/ <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: ' '�' <br /> TITLE:__ i GATE: o-D <br /> DEPARTMENT USE ONLY <br /> j! &/v%4v <br /> Application Accepted B. <br /> 1 Dat, 7W-0D---A= L O1 <br /> Gmt Inspection By.fdi�w�4-�-� __ Dates ll10-0Pump Inspected By Date <br /> Destnution Inspection BY Date <br /> COMMENTS: IA- ate.•- u S r ,,.r J°�8S <br /> PE SC AMOUNT CHE / RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# <br /> CODES INFO REMITTED CASM BY <br /> 3561 ib7 b ba 3/ <br />