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WELIMUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> /}JtO/EO/FEE...WEBER AVE.. STOCKTON CA 95202 12091M1 -M20 <br /> iJS �J ��O /" t�AB1.F�.FEEPJ�tTT EXPIRES YEARFROM DATE L55UEU <br /> JOB ADDRESS <br /> PARCP3,S[MAPN CCfY/LIP /^ <br /> OWNER NAME ADDRESS �7. �. <br /> CITYZP _PHONE <br /> CONTRA.T'I'OR 1 ��1;�_ADDRESS �U7 <br /> c YaJP �.-.--��L�r� [r�PxolaE C za c <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y_TOWNStlD•_ RANGE_SECTION <br /> TYPEOFWELL: O NEWWELL ❑ REPLACEMENTWELL ❑ MONITORAIGWELLF DOMES— <br /> INSTALLATION: ❑WELLSYSTEMREPAIR ❑CROSS-CONNECIREPAIR MP ❑VAPOREXTRACJIONW * <br /> r r <br /> TYPE OF POW: ❑NEW Y+,RfiPAIR H.P. sJ DEPTH PUMP SET_i(t/_-FT. FILSC WATER LEVEL�5 <br /> ❑OUT-OF-SERVICII WELL ❑GEOTECHNICAL x ❑SOIL BORING ❑DESTRUCTION <br /> w INTENDFDUSE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> O INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DG_ <br /> XyOMFSTIC PRIVATE OGRAVELPACMaII WELL CASING TYPE WELL CASING DIA <br /> Cl PUBLIC/MUNICIPAL ❑DRIVEN GROUTSEALDEPTH SPECH'ICATION <br /> O UtRMATIONIAG OTHERGROUTBRANDNAME <br /> ❑MONITORING GROUT SEAL POMPEII: ❑YES ONO <br /> ❑CNRLSTY BOX O STOVE PIPE CONCRETE PEDESTAL BY DRILLER: OYES ONO <br /> APPROXIMATE WELL DEPTH —(s <br /> PROPOSED CONSTRUCUON/DR111ING METHOD:MUD ROTARY_MR 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 /> JOAQUIN MUNCES,STA WS, RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED / <br /> TfILE: �i—P� DATE:IF I <br /> b 2' <br /> -------------- <br /> qw Tp <br /> rn <br /> DEPARTMENT USE ONLY <br /> AppScwion Aaptm By Dxtc ZI1 LL�� <br /> Gmut h pwtion B ---J)WPump Inspected By <br /> Desuucdon Im tion By D+te <br /> COMMENTS: <br /> PE SC AMOUNT CRECKx/ RECEIVED DATE PERMIT/SERVICEREQUESTx WELI.Im <br /> CODES INFO REMITTED CASH BY <br />