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/' I <br /> VjP--NL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUL EALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> A r'-N 304 E.WEBER NVE-, STOCKTON CA 95202 (209)468-3420 <br /> OBI ADDRESS � jON-�F�UNDABLE PERMIT EXPIRES 1 YEA$��SS DATE ISSUED <br /> PARCEL SIZE/APN 'plO `CITY6YMP <br /> OWNER NAME U l - ��! t ADDRESS 2-1-1 O J! MW A.A c4 <br /> / <br /> CITY/ZIP S d .NL Q kJ4-C f - PHONE [� / �7/� <br /> CONTRACTOR fC L4 1\-IL � ADDRESS ZV J)�7 C'lN/ <br /> CITY/ZIP PHONE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y /T'OWNSIIJP_ RANGE SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACFMENT WELL WELL# 3 ❑OTHER <br /> INSTALLATION: 0 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 /> Q OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING %r DESTRUCTION: 3 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION /J <br /> 13 INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DFA CONDUCTOR CASING DIA "t! <br /> ❑DOMESTIC PRIVATE 11 GRAVEL PACK/SIZE WELL CASING TYPES WELL CASING DIA <br /> . fir!! <br /> ❑POBLICIMUNICIPAL ❑DRIVEN GROUT SEAL DEPTH 5 SPECIFICATION <br /> ❑IRRIGATIONIAG OTHER GROUT BRAND NAME <br /> I <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES C-N6 <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ZC -TrS ❑NO <br /> I APPROXIMATE WELL DEPTH —al <br /> _ <br /> PROPOSED CONSTRUCTION/DRILLBJG METHOD: MUD ROTARAIR 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 COUNTY OR7A ' T AWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: Y <br />` TITLE: DATE: <br /> 1 <br /> �A+Ji=i� INIilU '(l' <br /> Uy!'G EAL FH,EFA 1 E' <br /> 1.17 <br /> r <br /> Aft <br /> (� <br /> DEPARTMENT USE ONLY <br /> Application Acc6ed Bj:,pu�t/-(,:� j 'y� '�--�..1 Date �� Areay <br /> Grout Inspeclio \� /y/� D gV Pump Inspected By Date <br /> Destruction Inspectti y/d1J /Date <br /> COMMENTS: .3 //(/6l n hC !�/ S f I Jia�G4 . �' A1�,.y �✓ I� <br /> PE SC AMOUNT CHEC I RECEIVED DATE PERMIT/SERVICE REQUEST WELL ID# <br /> CODES INFO REMITTED SH BY <br /> y3�s t,66 0 <br /> 2 aaa,l� <br />