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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL REALTY;DIVISION <br /> 304 E,WEBER AVE., STOCK9iDN CA 952D2 (209)668-9420 <br /> NON-REFUN114BLE PERMIT EXP, S I YEAR FROM DATE ISSUED <br /> 108 ADDRESS .69 lll'r <br /> PARCELSIZFjAPN_ CPI'YgtP <br /> OWNER NAME Y ADDRESS y y��... e <br /> N�IED <br /> CTIY2IP` PHONE <br /> CONTRACTOR_ <br /> ^ 'r ADDRESST7, <br /> ClTY2.IP�-JJ`�.��( 14ONB r`T <br /> GE0GRAPHICALINFORMAI70N; COORDINATES XC-- y-TOWNSHIP- RANGE_SECTION <br /> TYPE OF WELL: 0 NEW WELL 0 R$PLACEMENT WELL 0 MONITORING WELL k _p OTHER <br /> INSTALLATION: O WELL SYSTEM REPAIR O CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELLlr <br /> TYPE OF PUMP: O NEW REPAIR H.P. � ��• I WATER LEVEL�' L <br /> DEP'1T-I PUMPSFI FT. FIRS; <br /> ❑OUT OF-SPR VICE WELL 0 GEOT$CHMCAL M L]SOIL BORINO D I)FSTRUCTTON: <br /> INTENDFDUSE I TYpEQ£WELL CONSTRUCTION— ONS"TRUCTION SPECIFICATION <br /> O INDUSTRIAL O OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> )I DOMESTIC PRIVATE Q GRAVEL PACKISIZEL_ WELL CASING TYPE WELL,CASING DIA <br /> h O PUHLICIMUNICIPAL O DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME. <br /> ❑MONITORING `d�{�J E3 YES C3� <br /> O CHRISTY BOX O STOVE PIPE CONCRETE 1�3bRI� EX NO <br /> APPROXIMATE WP.LLDEPTH SZ `� U +'erT]it r�lr3 tr v f <br /> — Y ha e dVired withou i <br /> PROPOSED CONSTRUCTIONIDRILLIN❑MBTHOD: MUD ROTARY_4 AIR ROTAKY'rk 0TH <br /> rrrsee(. ed <br /> — <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TH£w'Owk'5W)BE Wf14C�Rp J�I�E WITH SAN <br /> JOAQUIN COUNTY ORDIANCFS,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN CO UN �i ° f.J11 1[} <br /> SIGNED: U `� <br /> i TITLE: <br /> i DATE <br /> ! I � <br /> I I <br /> i I <br /> ' r - <br /> W� 'A �� <br /> DEPARTMENT USE ONLY J1 �Xy U <br /> APPliminn Accepted$ ole ( aD V _yy <br /> Groin lnspec"urt Ry Oak <br /> Puirgl Inspected By uk,�$ <br /> Deslruclion Inspection 13y ate <br /> �. �//'v <br /> PC SC AMOUNT CHECKM RECEIVED DATE CODES INPERMITISERVICEREQUEST II WF[,Luyp <br /> FO REMI"I-I•ED gy <br />