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�' �� <br /> 7�'ARSpLL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY P. ,t HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ;'t, r _• `6 <br /> 304 E,WEBC.,AVE., STOCKTON CA 95202 (209}466-3420 <br /> I,, <br /> Ly PERMIT EXPIRES 1 YEA�{FR M D ATE ISSUED <br /> JOB ADDRESS 1(. J A C h �(,�J <br /> I PARCELSIZEJAP(N g CITY/ZIP f� (� <br /> OWNER NAME.,)C1 C r J/ ADDRESS_ f.�X 2-11 <br /> CITY/ZIP S d N-C—Q UAL C I/���- PHONE /� <br /> CONTRACTOR �� Z ADDRESS_ f2—C' ol <br /> CITYIZIP - f — f�—.-- <br /> PI{ONE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y—TOWNSHIP� RANGE_SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL 0-r IyONI70RING WELL# _ „❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: 11 NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> CI OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING 5(DESTRUCEON: 1 <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE f <br /> WELL CASING TYPE WALL CASING DIA <br /> k ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH �t SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES Q,t6 <br />! ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: Z?YE~ ❑NO <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY +fAIR 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 OR TA TA AWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, <br /> SIGNED; <br /> TITLE:11 DATE. <br /> 6 <br /> 3f� Ji: J-1N ou 'rY <br /> Ali <br /> AT <br /> i <br /> DEPARTMENT USE ONLY <br /> Application Acc ted B <br /> . /,� Date tl� Area•_�u��,� <br /> Groin Inspectio B j!?($y/jy/ np/iyy, D .� 60 pump Inspected By Date <br /> Destruction Inspecu <br /> Date <br /> COMMENTS: i'1 ?.Y"/ <br /> " fle�i.al•�riii�t <br /> PE SC AMOUNT CHEC RECEIVED DATE PERMIT/SERVICE REQUEST# WELL IDI! <br /> CODES INFO REMITTED SH BY <br /> f mon <br />