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I <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBL[CHEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304EWEBERAVE• STOCKTONCA95202 (209)468-3020 <br /> �U/ e/^ NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED / (!'1UA <br /> JOB ADDRESS J7 Oo2 �L ( rr�ayyl vil <br /> PARCEL SIZFJAPN CITY2I <br /> OWNER NAME _,ADDRESS [7R�FLL <br /> CITYZP-I / Q��PPHHONE � n <br /> CONIRAC�NR )b* r.0 r1.,:_ -�IDDREESSa/'Q' • ' �V- l� <br /> CITYZP C31a,. o, 9s30y PHONE bo!b <br /> GEOGRAPMCALINFORMATION.COORDINATES X_ Y_TOWNSHIP_ RANGE_SR-C1MON <br /> TYPEGFWEI.L: O NEWWELL ❑ REPLACEMENTWELL O MONITORING WELL# OOTHER <br /> INSTALLATION: rTLL <br /> SYSTEM REPAIR 11CROSS-CONNEC7 REPAIR O VAPOR EXTRACTION WELL# <br /> TYPEOFPUMP. -t(NEW ❑REPAIR H.P 1 !a DEPTH PUMP SET 800 FT. FIRSTWATERLEVEL _ <br /> (3OUC-OF-SERVICEWEU. ❑GEOTECHNICAL# OSOILBDRINC ODE MUCRON: <br /> INTENDED IN TYPE OF WEI.I. CON TE CTI N SP.CIFI ATION <br /> O INDUSTRIAL OOPEN BOTTOM WELLEXCAVATIONDIA CONDUCTOR CASING DIA_ <br /> ?,)GMESTEC PRIVATE ❑GRAVEL PACIUSIZE_ WELL CASING TYPE 57L WELLCASINGDIAV <br /> O PUBLIC/MUNICIPAL 0DRIVE.N GROUTSEALDLPTH SPECIFICATION- <br /> 13 UUUGATIONAG <br /> PECIFICATION❑UUUGATIONAG 24 HR NOTICE OTHER OROTT BRAND NAME <br /> ❑MONTfORINO REQUESTED <br /> FOf=l ALL GROUT SEAQ PUMPED: OYES ONO <br /> O CHRISTY BOX ❑STOVEPIPE INT Cl <br /> SS P ECC7 N TI S CONCREM PEDESTAL BY DRILLER O YES ONO <br /> IM <br /> APPROXATE WELL DEPTH 1 J <br /> PROPOSED CONSTRUCROMDRDIING MEIHM MUD ROTARY_AIR ROTARY_AUGER_CABLE_OTHER_ <br /> I HERESY CERTIFY THAT HAVE PREPARED THIS APPLICATION AND THAT THE WORE WILL BE DONE INACCORDANCE WITH SAN <br /> JOAQUIN UNTY ORD IANCFS,,.STATE <br /> ^LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: <br /> TITLE: DATE: <br /> R <br /> p` J <br /> h <br /> DEPARTMENT USE ONLY - <br /> AppOroOonAccep-Ily—k <br /> Gmut lnyraim By Dg Pump Impecw BY <br /> D.eion Invpecvon By Due <br /> COMMENTS: <br /> PE Sc AMOUNT AG�VED DAlE P # WELL IIM <br /> CODES INPD REMITTED H BY <br /> L <br />