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)f* -,L/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUB IALTH SERVICES ENVIRONMENTAL HEALTH DTVI O ;, �. <br /> LL <br /> 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED '� <br /> A R s 7 '�� Rkt_�< SON)) 77tlC3�1 CIC IC <br /> PARCEL SIZEIAPN CILU w C1TYlZIP L Ob 1 q 5z A z.. <br /> OWNERNAME_S O7rEt2 - 12M ADDRESS 1��h' TP.C.V� <br /> CITY/ZIP I.a q S Z. Z. PHONE <br /> CONTRACTOR ?CC ADDRESS 15 W LG1 W 000 Y fkk V F <br /> CITYMP S`r041C--r-0/J...._R5 205 PHONE <br /> CEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP_ R,1NGE_SECTION <br /> I, TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WILL p ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET -FTS..[_FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# XSOIL BORING ✓ ❑DESTRUCTION:NC� � ..,.. <br /> INTENDED USE TYPE IQF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE '❑GRAVEL PACK/SIZE WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> i ❑IRRIGATIONIAG ' 3 OTHER GROUT BRAND NAME <br /> 13TICS MONITORING a _ .E GROUT SEAL PUMPED: ❑YES q NO <br /> ED <br /> ❑CHRISTY BOX ❑STOVE PIPE = ? p. CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY_AIR ROTARY AUGER X CABLE <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCOR"FE WITH SAIsF'" <br /> JOAQUINCOUNTY RDIANC S, ATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. V I ')' <br /> SAV <br /> SIGNED: EfJ�,9P 1`�I,gQL'jvCpPov <br /> 777-LE- DATE: <br /> C <br /> rrt <br /> 1 <br /> d <br /> M <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date `t? Area <br /> Grout Inspection By -- `` Date} Pump Inspected By Date <br /> Destruction Inspection By 'TA rr'l�i / d/p`�Sy Date `� <br /> COMMENTS: <br /> '2-Cc�U � `�, 1-e-d lFIZ-2uoa �A'Mi�J3c1R ssf-�4rE .c�.�47 <br /> PE SC AMOUNC CHECK#1 RECEIVED DATE PERMITISERVICE REQUEST#f WELL ID# <br /> CODES INFO REMITTED CASH BY <br /> 4 V <br />