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_ WEL UM �95202 <br /> MIT J PAYMENT <br /> SAN JOAQUIN 304 G WEBER AVE,PUBLIC HE 7Ii ICES KIONENVIRONMENTAL <br /> r(2U9]r468-3420 ALTH DIVISIONRE�++E+VED <br /> NON-REFUNDABLEPERMITEXPIRES I YEAR FROM DATE ISSVED OCT - 4 2000 <br /> IOU ADDRESS 332 3„3 S. e4s77-IP R2) ri AC-G - cW *r <br /> PARCEL SIZEIAPNh O 90- 4 l CTTY2rp pUBIICNEAL'lAER Ipwts+rry <br /> OWNER NAME ' r � ADDRESS T617 &Lcztflt.-P bc- <br /> CiTYIZIP I C <br /> -- ry� L PHONE ♦ ` <br /> CONTRACTOR_ a�G�l�L I � ADDRESS fl.17 C p44ev-c o- br - <br /> CITYIZIP !fes`-?` ONE <br /> GEOGRAPHICAL INFORMATION: COORDINATES X, Y-TOWNSHIP_ RANGE_SECTION <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL k -❑OTHER <br /> INSTALLATION: ❑WELLSYSTEMREPAIR ❑CR/OS$-CONNECI'REPAIR 17 VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: NEW ❑REPAIR H.P. f Y2r DEPTH PUMP SET_ C�, FIRST WATER LEVEL <br /> ❑OUT-0F-SERVICE WELL ❑GEOTECHNICAL A O SOIL BORING ❑DESTRUCTION; <br /> [N7'F;NbEn USE TYPE OFWEU C2(NSTRUCTION SPE _rvrCATIOIY <br /> K3 INDUSTRIAL XOPENBOTTOMWELLEXCAVATIONDEA CONDUCTOR CASING DIA_ <br /> Cl DOMESTIC PRIVATE ❑GRAVEL PACKJSIZE �r� +t <br /> WELL CASING TYPE J 1 Z + WELL CASING DIAD <br /> 0 PUBLICJMUNICIPAL ❑DRIVEN GROUT SEAL DEPTH V AJX .SPECIFICATION <br /> �RRIGATIONIAG <br /> OTHER GROUT BRAND NAME <br /> 1:1 MONITORING 24. HR N OTl 'SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTYBOX 13 STOVE PIPE REOUE.STEC7 <br /> �L_L CONCRLM PEDESTAL BY DRILLER: ❑YES i]NO <br /> APPROXIMATE WELL DEPTH S P GTI Q N S <br /> PROPOSED CONSTRUCTIONIDRILLWO METHOD- MUD ROTARY-AIR ROTARY AUGER_CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORE WILL BE DONE IN ACCORDANCE WITH SAN <br /> J OAQUIN COUNTY ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTYQm, <br /> SIGNED r�� <br /> TITLE: DATE: <br /> I <br /> EF <br /> i <br /> I <br /> i <br /> I <br /> I <br /> _ r <br /> ! ` I <br /> I � <br /> - I i <br /> EPARTMENT USE ONLY <br /> ApplicGion Aa:epled By <br /> Date `Aja <br /> Grout fnapection By Da[e <br /> Pump Inspecletl By Datr ✓�2`�l�i�'� <br /> De9nucLo7s in,pection By <br /> atr'— <br /> COMMENTS: WV - <br /> ��•-� <br /> PE SC AMOUNT CHECK#/ RECEIV DATE PERM <br /> CODFS INFO it CASH CASH BY IMS?'I WRLL1Dp <br /> i <br />