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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 4 <br /> ON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS I.E. COPPEP.. OF REEVE RD. rPND BYPON HIIY <br /> PARCEL SIZE/APN CI y,, T P A C Y <br /> oWNERNAME SAr� bZIZ ADDRESS 1832 PP.RADISE VALLEY CT. <br /> CITY/zIp TOACY, CA, 95376 PHONE 633-0813 <br /> CONTRACTOR HEN'i!INS 2ROS. DPILLINGADDREss 3525 PELAPDALE AVE, <br /> CITY/zIp tIODESTO, CA 95356 PHONE 545-1185 RECEIVED <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP_ RANGE SECTION MAY m 12001 <br /> TYPE OF WELL: OX NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# 'OUIN COUNTY <br /> ENVIRONMENTAL HEALTH DIVISION <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA 12 11 CONDUCTOR CASING DIA <br /> 0 DOMESTIC PRIVATE C,l GRAVEL PACK/SIZE WELL CASING TYPE PVC WELL CASING DIA 5 u <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH 10 0 t SPECIFICATION BET1t0Illte <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME BARJOID <br /> ❑MONITORING GROUT SEAL PUMPED: X7 YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE // /I''•• CONCRETE PEDESTAL BY DRILLER: ❑YES ),`]NO <br /> APPROXIMATE WELL DEPTH <br /> t ( L1 <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY X AIR ROTARY AUGER CABLE OTHER <br /> ' I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUnNT,Y_O_R_D•I_ANCLEy(S,,�STATE LAWS,AND RULES AND RE <br /> *'1U�yLATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED <br /> TITLE: SUPERVISOR, DATE: MAY 1 , 2001 <br /> n <br /> -- r - <br /> 05 <br /> -I <br /> S41 <br /> ONLY f� <br /> Application Accepted By Date l7 _Area L' r <br /> Grout Inspection By Date-6 (-p /Pump Inspected By Date <br /> Destruction Inspection By Date <br /> COMMENTS: <br /> PE SC AMOUNT CHECK#/ RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# <br /> CODES INFO REM[ITTEQ CASH BY <br /> 014 - . a 5 <br />