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ELL/PUMP PERMIT h AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 NON-REF[JNDABLE PERMIT EXPIRES 1 YEAR FROM DATE I55UE `� JOB ries Road ; PARCEL SIZEIAPN CITY/ZIP Lodi 95242 OWNERNAME i�iChelle Stanton ADDkESSIe CITY/ZIP PHONE 367-5596 TEUM P CONTRACTOR Delta PllIllp ADDRESS 646 S. California Street CITYrZIP StOCkton' 95203 PHONE 466-9625 GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION i TYPE OF WELL: ❑ NEW WELL. Cl REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER INSTALLATION: ❑WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# TYPE OF PUMP: ❑ NEW REPAIR H.P. DEPTH PUMP SET PTI FIRST WATER LEVEL ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING 0 DESTRUCTION: INTENDED USE, TYPE OF WELL CONSTRUCTION SPECIFICATION ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA 1 ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELL CASING DIA ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION ❑IRRIGATION/AG OTHER GROUT BRAND NAME ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO ❑C14RISTY BOX ❑"STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO APPROXIMATE WELL DEPTH PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN . JOAQUIN COUNTY ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. SIGNED: 1 h }# TITLE: OMer 1 DATE:_1/3/01 -- 1 a C t - ()A 01 7dV lLT ur TY 2 LE DEPARTMENT USE ONLY Application Accepted By A Date_ a/ 9 2 FArea Grout Inspection By Date Pump Inspected By Date i Destruction Inspection By a(7 Date i COMMENTS: *I Z^OZ —COIN 5/Lk� `4_CD 4'6XT d DAJVIIC44Z PE_ SC AMOUNT ECK#1 RECEIVED DATE PERMITISERVICE REQUEST# WELL ID# i CODES INFO REMITTED BY