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6wWELU/PUN }ERMTT <br /> ,Yell SAN JOAQUIN COUNTY PUBLIC HEALTH SER VRF$ENVIRONMENTAL HEALTH DIVISION �c) <br /> 1 1 314E.WEBERAVE.. STOCKTONCA95202 (2091469-3120 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ` 10B ADDRESS G-1/i <br /> PARCELSTLFIAPN ©y3-&13o-Sy CITYa1P V <br /> OWNER NAME_16 1 R1 T ADDRESS <br /> L Ci TY/IIP PHONE /^ <br /> CONTRACCG�O+aR� (i �— ADDRESS � �I / Y? <br /> < y p I- <br /> CITYaiP <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y_TOWNSHIP_ RANGE_SECTION <br /> TYPEOFWELL: ❑ NEWWELL O KEPLACEMENTWELL ❑ MONITORING WELL# Cl OTHER <br /> INSTALLATION: IXWELLSYSTEMREPAIR ❑CROSS-C NNECTREPAIR ❑VAPOREXTRACOONWELLN <br /> TYPEOFPUMP: 'NEW ❑REPAIR H.P. DEPTH PUMPSET /e2 FT. FIRST WATER LEVEL/__ <br /> ❑OUT-OF_SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TVPEOFWELL CONSTRUCTION SPECIFICATION <br /> r <br /> ❑INDUS'TRIAL ❑OPEN BOTTOM WELLEXCAVATIONDIA_ CONDUCTOR CASING DIA_ <br /> F,DOMESTIC PRIVATE ❑GRAVEL PACK/SILE WELL CASING TYPE WELL CASING DIA <br /> ❑PUBLICMUNICIPAL ❑DRIVEN GROUTSEALDF.PT11 SPECIFICATION <br /> O IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUTSEALPUMPED: OYES ONO <br /> ` ❑CHRISTY BOX O STOVE PIPE CONCRETE PEDESTAL BY DRILLER: OYES ❑NO <br /> r <br /> APPROXIMATE WELL DEPTH E.,2- <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY_AIR ROTARY_AUGER_CABLE_OTHER_ <br /> I HEREBY CERTIFY THAT I HAVE PREPARED IHS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDIANCES, ELA ,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: <br /> rN TITLE: �fU/ DATE: <br /> Y#� <br /> L <br /> F <br /> ' n m <br /> r.. <br /> DEPARTMENT USE ONLY �S��yE�ggt�(IL <br /> Applicaion Acce 1pleB By � �� 1 <br />