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1 +I.L/PUMP PERMIT I — <br /> ` SAN JOAQUIN(7OI INTY I'{.. I11,1.11I.SERV IC'liti l:N V I fONMHN'I'AI.I IIiAIa'l l l)]V ISION <br /> UMP <br /> STOCKTONCA95202 (209)46H-3420 ♦♦ h <br /> J P NUN•11ITPNIYAlll E I'IiRh11T I Xl'Y1tb;S 11'EAR FRONt DA Ili ISSULIA) E + PUMP`V` <br /> �{� ` -= # <br /> 3�1fG]DRJiSS�, <br /> PARCELSIZE/APNAgge-a Uhe 7.111-4vo,-ZI C]'1'YfLIP ��rT4�eU0!• <br /> OWNER NAMENIC ftN D0 ADDRESS <br /> CITY/ZIP PHONE <br /> �^ <br /> CONTRACTOR�CLYw.nl �a+1 �• 714 a ADDRESS �_In 0l/D" <br /> CITY(LIP 1 Fa'Y7"JA "� PHONE- �`"! b� <br /> + <br /> GEOGRAPHICAL INFORMATION. COORDINATES_'X___ Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# 1a OTHERRs•�bfL I nrS <br /> 1 INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH.PUMP SET FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# SOIL BORING J21 DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAT{ON <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DEA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACKlSIZE WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLIClMUNICIPAL ❑ORIVFN GROITTSEALDlil°I'II SPISCIPICATION <br /> ❑IRRMATIONIAG O'1IIIfR(IROI)T IIRAND NAMP <br /> ❑MONI'T'ORING GROUP SUAL PUMPED: I$YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES 'W NO <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> 3OAQUIN COUNTY ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED:_,. <br /> { TITLE: eK.0 Ild C-(I- DATE: V1 <br /> a <br /> No- <br /> S� <br /> Application Accepted Datc l:�1 Ar" - <br /> r <br /> Grout Inspection By Date Pump Inspected By ._.—ter <br /> Destruction Inspection By �QrZ`�T '�t� I'd I Date �� 4��F <br /> - <br /> ' COMMENTS: - <br /> ' kTA.kFrq T�`IOES <br /> nlv�1. <br /> PE SC AMOUNT V}{E RECEIVED DATE PERMITISERVICE REQUEST# WELL IDN <br /> CODES INFO REMITTED CASH BY <br />