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f - } WELL/PUMP PERMIT PAYMENT SAN JOAQUINCOUNTY PUBLIC HEALTH SERVICES ENVIRONME1v_AL HEALTH DIVISION RECEIVED--: --301 E.WEBER AVE., STOCKTON CA 95202 (209)468-342Q ks r p NON-REFUND ABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEb SUG P f 2 2 fw'S P JOB ADDRESS PARCEL SIZE/APN 62 �� [ CITY/ZIP PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH OIV1910P OWNER NAME MQr ADDRESS-?_C-C(- _ ad CITY/ZIP r,:j PHONE , , CONTRACTOR�I J� l , ADDRESS _Xf , _ — CITY/ZIP '� PHONE_�'I � lam✓' ._.__ ..-. •__ GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION TYPE OF WELL: v NEW WELL ❑ REPLACEMENT WELL C] MONITORING WELL# ❑OTHER INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# TYPE OF PUMP: �NEW ❑REPAIR H.P, DEPTH PUMPSET �Fr. FIRST WATER LEVEL❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: ! INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAT/ION ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DI��P ,CONDUCTOR CASING DIA ❑DOMESTIC PRIVATE RAVEL PACK/SIZE WELL CASING TYPP.�� WELL CASING DIA �� [ ❑PUBLIC/MUNICIPAL d DRIVEN GROUT SEAL DEPTH s`4 SPECIFICATION G _ IRRIGATION/AG C l OTHER GROUT BRAND NAME ❑MONITORING fi GROUT SEAL PUMPED: ❑YES ❑NO -�A �Q ❑CHRISTY BOX ❑STOVE PIPE 7'� CONCRETE PEDESTAL BY DRILLER: DYES ❑NO APPROXIMATE WELL DEPTH lie �-- PROPOSED CONSTRUCTIONMRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER e I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TETE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY O IANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. SIG TITLE: _ DATE: Ln of C N ' a f 0 _ 4.�_._•_.__ DEPARTMENT USE ONLY Application Accepted By LAADateV Area_42 1 i Grout Inspection By Date <�•40'2Pump Inspected By Date Destruction Inspection tl -pq Date COMMENTS: ^14� (vE 5 8,, me?- J r&-Le 5 t k/" ;*I- 7- PE SC AMOUNT" C ECK#/ RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# ' CODES INFO REMITTED BY