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WELL/PUMP PERMIT \ <br /> PAYMENT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION RECEIVED--y <br /> 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 r 4 <br /> i `'. - <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . 2 '2 2000 <br /> JOB ADDRESS �s'C_ -s <br /> - <br /> PUBLIC HEALTH SERVICES <br /> PARCEL SIZE/APN �52 1 CITY/ZIP } l', l ENVIRONMf ENVIRONMENTAL HEALTH DIVISION <br /> OWNER NAME � r ;fes. 1. `DLAbDRESS <br /> r CITY/ZIP�Id 'i yY-PHONE <br /> CONTRACTOR <br /> DDRESS <br /> FCITY/ZIP -' f �l PHONE ` I <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> FTYPE OF WELL: V NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# LI OTHER <br /> t INSTALLATION: 11 WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR 13 VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: Y.." W ❑REPAIR H.P. DEPTH PUMP SET67 12�_FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> FINTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> y ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA7Z4'; CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE RAVEL PACK/SIZE WELL CASING TYP �' WELL CASING DIA <br /> 1 <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH.st� _ SPECIFICATION- <br /> IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING Irl C GROUT SEAL PUMPED: ❑YES ❑NO a <br /> [� ❑CHRISTY BOX ❑STOVE PIPE r`1 S�' CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO I <br /> F APPROXIMATE WELL DEPTH <br /> E <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY <br /> AIR ROTARY AUGER CABLE OTHERe <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY O ANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. O <br /> - SIG <br /> TITLE: <br /> DATE: V <br /> I o w, <br /> i (V <br /> c g Q!Er CL <br /> �/ <br /> 0 <br />