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`+- WELL/PUMP PERMIT the <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ' <br /> 304 E.WEBER AVE., STOCKTON CA 95202 +Wc <br /> (209)468-3420 xra <br /> ^ ^ ^ NON-R'FUND LE PERMI EXPIIS EAR FROM DATE ISSUED Q <br /> —DSD <br /> JOB ADDRESS I D`D <br />\I PARCEL SIZE/APN CITY/ZIP L0 <br /> OWNERNA(vII?_.D_ ._S�C� --- �Ir I>URIiSS__ S_a� <br /> CITY/ZIP �d ( _7r ---- <br /> PHONE 3 � z/2- <br /> -A <br /> /2— <br /> _!CONTRACTORC ( P ADDRESS <br /> CITY/ZIP S ' VDO 3 —P� PHONE_ E/(/ 2 <br /> [GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> YPE OF WELL: NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> NSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET IT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOMf( <br /> WELL EXCAVATION DIA _ CONDUCTOR CASING DIA <br /> OMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE—PL WELL CASING DIA lZ <br /> ❑PUBLIC/MUNICIPAL f <br /> ❑DRIVEN GROUT SEAL DEPTHO SPECIFICATIOPN C <br /> ❑IRRIGATION/AG OTI IFR 6ROUI•BRAND NAMG__� <br /> ❑MONITORING GROUT SEAL PUMPED: UXLS ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: Q.J�S ❑NO <br /> APPROXIMATE WELL DEPTH (I/ )� <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY � 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 COUNTY ORDIANCES,. WS.AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: <br /> TITLE: DATE: 3 <br /> 00, <br /> Mph <br /> N <br /> i <br /> � 1 <br /> 7 <br /> C <br /> � �EPARTN ENT USF,ONLY <br /> Application Accepted By f o Date 3u Area <br /> Grout Inspection By L U Date �Pump Inspected By Date <br /> Destruction Inspection By Date <br /> COMMENTS: <br /> PE SC I AMOUNTECK P RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# <br /> CODES INFO REMITTAD CASH BY <br /> 40 +�L �Uc.3 vv�CU f <br /> f <br />