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WELL/PUMP PERMIT x132�oo�/ <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304E.WEBERAVE., STOCKTONCA95202 (209)466-3420 PAYMENT <br /> NON-REFUNDABLE.PERMIT EXPIRRS I YEAR FROM DATE ISSUE c RECEIVED D� <br /> JOB ADDRESS 1q C Ld F- : <br /> PARCEL SIZFJAPN_�14 Aer f/ CITYmP {�/1 N A-iN_ �)O <br /> S D //�rr'/4 ti' ADDRESS f .0, j��7 ENVIRONMENTAL REASAN 1QAQ'If"PUBLIC HEALTH ETRF+N0MSI0N <br /> OWNERN SS <br /> CITYrZIP C PHONE_ <br /> CONTRACTOR e ' /� DRES,SS �0.� 2 957 3� <br /> CITY/LTP PHONEY <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y_TOWNSHIP_ RANGE_SECTION <br /> TYPE OF WELL: b P1EW WELL REPLACEMENT WELL O MONITORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR 13 CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: &<W O REPAIR H.P. _ DEPTH PUMP SET-,—/& ET. FIRST WATER LEVEL _ <br /> ❑OUT-OF-SERVICE WELL 13 GEOTECHNICAL# ❑SOIL BORING 13 DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA ii CONDUCTOR CASING DIA <br /> MESTIC PRIVATE ❑GRAVEL PACK/SIZE* WELL CASING TYPE Aye • WELL CASING DIA_ _ <br /> ❑PUBLIC/MUNICIPAL 17 DRIVEN GROUT SEAL DEPTHa 012Q SPEjCIFICAT_I,ON <br /> ❑IRRIGATIONIAG OTHER GROUT BRAND NAME / -sE <.4, .,/ <br /> 24 I-II �, NICE <br /> 13 ,,t� <br /> MONITORING k <br /> GROUT SEAL PUMPED: r ES ❑NO <br /> ❑CHRISTY BOX O STOVE PSE I F-Q;_-( A I_L CONCRETE PEDESTAL BY DRILLER: 60PES ❑NO <br /> J� <br /> APPROXIMATE WELL DEPTH - TICNS'/ <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY v AIR ROTARY_AUGER_ <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL B' <br /> JOAQUIN COUNTY ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIP <br /> SIGNED: <br /> TITLE: /✓ /'Y° —DATE: L I I <br /> 711 <br /> t <br /> LP <br /> I .5 ' >e q �a �q 1(y�' <br /> _ __ Jor D TMENT USE ONLY.. <br /> Application Accepted By ...7�-- <br /> Grout Date o' -06h'Pump Inspected By ,yf <br /> Destruction Inspection By <br /> COMMENTS: <br /> PE SC AMOUNT ECK#/ RECEIVED DATE PERMIT/SERVICE REQ <br /> ­ <br /> —CODES INFO REMITTED BY <br /> 5'7' 1 t <br /> q 3 g' <br />