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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES E:WIRONMENTAL HEALTH DIVISION i. <br /> 304 E.WEBER AVE., STOCKTON CA 95202 `'tea <br /> (209)468-3420 <br /> 23 2-LI NON-R FUND LE PERMEXPIT ITAR FROM DATE ISSUED O _ >i <br /> JOB ADDRESS <br /> PARCELSIZE/APN CITY/ZIP LO I 2y - <br /> j� sad <br /> OWNI:R NAME, r` I)I)ItIaS <br /> CI"I'Y/LII' <br /> Lo 2�� 3 6/ <br /> J �� )�^ PHONE (f `/2 7 <br /> CONTRACTO((��R�7�C/�(-!1�T71-r�l�� JVl/LQ-L ADDRESS <br /> e. CITYlZIP J ' V l L (l`� ( � PHONE_ E16 2 <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 EXTRAC770N WELL# <br /> i <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTII PUMP SEI FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECIINICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> 1 ❑INDUSTRIAL ❑OPEN BOTTOM �[ f( <br /> ��'ELL EXCAVATION DI?,1L CONDUCTOR CASING DIA <br /> OMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE py WELL CASING DIA lZ <br /> ❑PUBLIC/MUNICIPAL1 <br /> ❑DRIVEN GROUT SEAL DEPTH. � S�IPECII=ICATI�+N <br /> ❑IRRIGATION/AG OTHER GROUTBRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: (1AT5' ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: C>� ❑NO <br /> APPROXIMATE WELL DEPTH_ <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE <br /> OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> T <br /> JOAQUIN COUNTY ORDIANCES, W ,AND RULES AND REGULATION'S OF SAN JOAQUIN COUNTY, <br /> j SIGNED: <br /> TITLE: DATE: <br /> i <br /> 1 I <br /> FN IiCn e F <br /> I � <br />