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pm l <br /> `► WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 <br /> + ^'�(� NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> r JOB ADDRESS 1 I 1 l Imo) }ns^I <br /> PARCELSIZE/ CITY/ZIP l ch , ( 6`/�`� �7L� <br /> r OWNER NAMEto 13ireama'nADDRESS � ac)I T . 't"10-al .V/�1 <br /> ) r) � '1- <br /> CTJY/Z@ ('` i' J PHONE <br /> CONTRACTO 7 ADDRESS 2I (. 16 -��• <br /> CITY/ZIY-- + -C71GT PHONE CJI -6;)J <br /> r <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y_ TOWNSHIP_ RANGE_ SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL k ❑OTHER <br /> �. <br /> INSTALLATION: 13 WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL N <br /> TT'YPE DUMP: �T7 REPAIR H.P.,Il D PTH P P SET FIR ATER LEVEL <br /> r O - O - "❑G$ST�I ��t�1'`QC ❑ RIN -r ❑ UCITON: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> r O INDUSTRIAL O OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA_ <br /> ❑DOMESTIC PRIVATE O GRAVEL PACK/SIZE— WELL CASING TYPE WELL CASING DIA <br /> r ❑PUBLIC/MUNICIPAL O DRIVEN GROUT SEAL DEPTH <br /> SPECIFICATION—OTHER GROUT BRAND NAME <br /> 24 HR NOTICE <br /> O MONITORING R E Q U E STE.LJGROUT SEAL P ED: ❑YES ONO <br /> r <br /> O CHRISTY BOX ❑STOVE PIPE F'D%:l A L L CONCRETE PE ESTAL BY DRILLER: ❑YES ❑NO <br /> INSPECTIONS <br /> APPROXIMATE WELL DEPTH— <br /> PROPOSED <br /> EPTH _PROPOSED CONSTRUCTION/DRB-LING METHOD: MUD ROTARY_AIR ROTARY_A GER_CABLE_ OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK ILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JO QUIN COUNTY. <br /> SIGNED: <br /> TITLE: i. DATE: <br /> r <br /> r <br /> r <br /> r <br /> r <br />