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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DI <br /> 304 E.WEBER AVF.. WOCKMN CA 95202 (209)468-34M <br /> /y �NON-REFUNDABLE PE T EXP[RFS 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS_/O'3 6-A� f. V U <br /> PARCEL S17.FJAFN} ]'8J 0n cl r ir'r s'_ CITYILIP on,n4V <br /> OWNFJtL_)ADDRFSS ! r C, 47A61 <br /> _ <br /> CITYfLIP L oai S PHONE~ - - <br /> CONTRACTOR- 1-,ao�i�ES-';"!X DDRESs Pi-?D I N, /co' � s/"►A wt Alm <br /> CITYMP2 ,20kOCI PHONE Cl_Lda <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y TOWNSHIP_ RANCE_SECTION <br /> TYPEOFWELL: 9? NEWWELL 0 KU- LACEMENTWELL 0 MONrTORINGWELLB 13 OTHER <br /> INSTALLATION: Q WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL 0 <br /> TYPF.OFPUMP: *NEW OREPAIR H.P. DEPTHPUMPSETIrCO Fr. FIRST WATER LEVEL J[JQ <br /> 3)7 <br /> -OP•SERVICE WELL 0 GEOTECHNICAL 0 0501L BORING 0 DESTRUCTION:INTENDED USE TYPF,OF WELL CONSTRUCTION.SPECIFICATION <br /> 0 INDUSTRIAL 0 OPEN BOTTOM WELL EXCAVATION DIA a Q. CONDUCTOR CASING DIA <br /> ' t <br /> 11 DOMESTIC PRIVATE *GRAVEL PACKlSi7^F.,�„_ WELL CASING TYPE 5 br 1JJ WELL CASING DIA <br /> ❑PUBLICIMUNiCIPAL 0 DRIVENROUT SEAL DEPTH S_0' SPECIFICATION <br /> 24 HR NC>TICE <br /> 49IRRIGATI0NIAG R E GI U E ST E C3 OTHER GROUT BRAND NAME__&d_ LW_C+C <br /> C <br /> CT MONITORING F(DR ALL GROUT SEAT.PUMPED: 0 YES 0 NO <br /> INSPEGTI(DNS <br /> D CHRISTY BOX 0 STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ADNO <br /> APPROXIMATE WELL DEPTH �7 S 1 �, <br /> - NAYMLp, <br /> PROPOSF,D CONSTRUCrIONIDRELLINO ML-MOD: MUD ROTARY_AIR ROTARY AUGER CABLE R 11QIiFd _� <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN$CGO • A CE WITH SAN <br /> JOAQUIN COUN ORDIANCES,STATE LAWS,AND RULES AND REGU.ATIONS OF SAN JOAQUIN COUNTY. / <br /> 19 b <br /> SAN JC)Au aro��GUr�' <br /> SIGNED: PULL(fI�A Tu ^y�r, <br /> TITLE: ATE: I/ aZ-'!� <br /> I <br /> we It i <br /> I � <br /> j <br /> i 1 <br /> DEPARTmENj USE ONLY c_ <br /> Application AxcptcA Br vw �` Dam _J V <br /> Grout Itupac6on By 4 alc PUMP Inspected By� <br /> Denructicn Irspecrion Ay Date <br /> COMIMENTS:C9�Y1yln���G�� Lf d" ,�-L-1 4 •d) <br /> IV <br /> PE SC I AMOUNT gBECW RECEIVED DATE PE T H WFI.L IEH1 <br /> CODES INFO REMITTED 'ASH BY <br /> ✓/s � �� 1�r' � �I�00�S <br /> y V ? 7 osz> <br /> Ll ►fib <br /> a <br />