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1 <br /> WELL/PUMP IT <br /> -r f S4WOAQUIN COUNTY PUBLIC HEALTH SERV10Ea ENVIRONMENTAL HEALTH DIVISION <br /> ' 304 E.WEBER AVE., STOCKTONCA 95202 (209)468-3426 <br /> v <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADI ��14 �� "+-• <br /> l PAR SMUAPN_ / - -_CITYMF <br /> OWNER NAME / � ADDRLSS _ �r <br /> CITYmP_, <br /> CONTRACTOR ADDRESS <br /> CTTYrZ[P - PHONE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y—TOWNSHIPi RANGE_SECTION <br /> TYPE OF WELL:XNEW WELL 0 REPLACEMENT WELL E3 MONITORING WELL# ❑OTHER <br /> INSTALLATION: q WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: &-7NEW O REPAIR H.P. B12 DEPTH PUMP SET �yy r � <br /> FT. FIRST WATER LEVEL �S^ <br /> 0 OUT-OF-SERVICE WELL q GEOTECHNICAL# O SOIL BORING 0 DESTRUCTION: <br /> INTENDED USE TYPE OF y1 ELL CONSTRUCTION SPECIFICATION I <br /> 0 INDUSTRIAL 0 OPEN BOTTOM WELL EXCAVATION DIA /Z� CONDUCTOR CASING DIA <br /> 6MEST[C PRIVATE RAVEL PACK/SIZEWELL CASING TYPE WELL CASING DIA_, Ig 1 <br /> ❑PUBLICIMUMCIPAL ❑DRIVE <br /> GROUT SEAL DEPTH SpECIFTCATION� <br /> 0 IRRIGATION/AG 24 "R N C)-Fl C EDTHER GROUT BRAND NAME <br /> ❑MONITORING R C) R A L L ID GROUT SEAL PUMPED: �S ❑NO <br /> ❑CHRISTY BOX 13 STOVE PIPE�jI�N, S p E CTI C)N SCONCRETE PEDESTAL BY DRILLER: ❑YES <br /> APPROXIMATE WELL DEPTH Ll—:5 <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARYA2AIR 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 COU AA{LC ,ST ND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: <br /> TITLE: <br /> 1 <br /> A414 SU VV <br /> Y <br /> k <br /> NN1 ffiALTLD1 iSk <br /> �_. DEPARTMENT USE ONLY <br /> Application Accepted By L 3 Dale O�Arca v <br /> "/--,�- <br /> Grout Inspection By Date q6ump Inspected By Date//,,��Q <br /> Destruction Inspection By (/r <br /> Date <br /> COMMENTS: - <br /> SC AMOUNT HECK# RECEIVED DATE- PERMITISERVICEREQUEST# WELLID9 I <br /> INFO EMITTED BY <br />