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/.'3a <br /> WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 <br /> P <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUEp _ �-Z �•, <br /> JOB ADDRESS /9w-0 !l I Ii& K/ <br /> PARCELSIZF/AjjPN T� /7`�1^S CITY/ZIP <br /> �� (7 o� <br /> OWNER NAME CS VQ W NS I&�_ f0D U..ALI�ADDRESS Ar' OO I Wy' P f �( <br /> CITYrzIP <br /> C� PHONE <br /> � <br /> CONTRACTOR\00"%-� S �wt[ )4,T-ADDRESS I��LJY� — <br /> CITY,,, Y ✓l t9 L l4-D lel PHONE �LZ—�1�</I <br /> L <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP_ RANGE_SECTION <br /> TYPE OF WELL: KNEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <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-0F-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> /l <br /> ❑INDUSTRIAL If <br /> •❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA- <br /> 0 DOMESTIC PRIVATE /�GRAVEL PACK/SIZE WELL CASING TYPE WELL CASING DIA. [/ <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION- <br /> IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING 24 "R NOT 1 C E GROUT SEAL PUMPED: D4(-m ❑NO <br /> RFC;?u1=S-FEo <br /> ❑CHRISTY BOX ❑STOVE PIPE F Q FI A L!_ CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> APPROXIMATE WELL DEPTH t' 2 P ECTI O Imo!S <br /> - PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY�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 COUNTY ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: \ L <br /> t <br /> TITLE: .....�DATE: <br /> ` 1 <br /> RVA 1v <br /> Ai <br /> �44i <br /> DEPARTMENT ONLY <br /> Application Accepte4By <br /> [ \ Date <br /> Grout Inspection By Date.�r�ump Inspected By PAY' <br /> Destruction InspectiDatef n f= <br /> COMMENTS: <br /> DEC <br /> �,Ir.cont <br /> PE SC AMOUNT (CHECKV RECEIVED DATE PERMIT/SERVICE # <br /> REQUEST <br /> CODES INFO REMITTED BY Q <br />