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o� WELL/PUMP PERMIT <br /> A �IN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HE DI N <br /> 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-342 <br /> V� ICON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE IS UMP <br /> JOB Al <br /> PARCEL�IZE/APN n' CITY/ZIP_SjV 1 f <br /> OWNER NAME Ctn AYAI moi, c�I -� +Dt(-A DKESS 1 6D"[ <br /> a <br /> Y/JPP 9 5 !✓ -S PH NE Cl 7i <br /> t <br /> RACTOK E <br /> CITY/ZIP - PHONE <br /> GEOGRAPHICAL INFORMATION: COORDI E X Y TOWNSHIP RANGE SECTION +3 <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# OTHER CT1 0ri'll <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# 1 OIL BORING _ ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE <br /> WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH So SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: <br /> YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES 0 <br /> APPROXIMATE WELL DEPTH l <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 IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED:'. <br /> TITLE: DATE: <br /> i <br /> O <br /> 8 <br /> � EN IR , M NL L H?L . C.✓tS! h , <br /> DE'��`�F.NT USE ONLY <br /> Application Accepted By (,(/t, <br /> Date — Area <br /> Grout Inspection By Date Pump Inspected By <br /> Date <br /> Destruction Inspection By <br /> Date <br /> COMMENTS: <br /> PE SC AMOUNT HE / RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# <br /> CODES INFO REMITTED SH By <br /> 4 .3 <br />