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C) <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT ERES I YEAR FROM DATE ISSUED WELL <br /> JOB ADDRESS L \ <br /> PARCEL SIZEIAPN O .4 12- f CITYIZIP <br /> OWNER NAME V`�3` o ADDRESS <br /> CITYIZIP l PHONE 3 X03 <br /> CONTRACTOR ADDRESS 113 <br /> CITYIZIP IL �6m PHONE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR El CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> i1 <br /> TYPE OF PUMP: NEW ❑REPAIR ILP. DEPTH PUMP SET 2 )-FT. FIRST WATER LEVEL SIC <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ®DOMESTIC PRIVATE ❑GRAVEL PACKISIZE WELL CASING TYPE WELL CASING DIA <br /> 1❑�PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES Cl NO �s <br /> I <br /> 11 CHRISTY BOX 11 STOVE PIPE CONCRETE PEDESTAL BY DRILLER: OYES ❑NO <br /> APPROXIMATE WELL DEPTH <br /> (1 <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> HEREBY CERTIFY THAT IlHAVE 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 /> S <br /> SIGNED: � <br /> TITLE: ®1 Q DATE: <br /> :# <br /> 41 <br /> Fu <br /> I <br /> k <br /> � • H 'u'i�Hy.6F�:� <br /> li <br /> i it - <br />