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n <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 E RES I YEAR FROM DATE ISSUED WE L L ' <br /> JOB ADDRESS <br /> ''y � l✓ <br /> PARCEL SIZE/APN d { ` 71CITY/ZIP C,A Q\% 0\.ck <br /> OWNER NAMEADDRESS . <br /> CITY/ZIP PHONE <br /> CONTRACTOR \�!! i c�AADDRESS_���� 1 V• ��A�� .� �]VQ� <br /> PHONE- <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: ❑ NEW WELL 0 REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: I NEW ❑REPAIR H.P. DEPTH PUMP SET_la FI. FIRST WATER LEVEL S O� <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> i <br /> INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA r, CONDUCTOR CASING DIA <br /> ql DOMESTIC PRIVATE 11GRAVEL PACK/SIZE WELL CASING TYPEAN Q- WELL CASING DIA <br /> ❑PUBLICIMUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO �+ <br /> 11 ,P ❑CHRISTY BOX ❑STOVE PIPE r� I CONCRETE PEDESTAL,BY DRILLER: ❑YES ❑NO <br /> 1� APPROXIMATE WELL DEPTH OS l�f <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> HEREBY CERTIFY THAT 1 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 /> a TITLE \QNJ _ ...,„ DATE: _lb <br /> ii <br /> ;i <br /> i <br /> I <br /> I <br /> �I s . � • c� try � �1- <br /> �I <br />