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WELL/PUMP PERMIT t <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTS DIVISION <br /> 364 E.WEBER AVE., STOCKTON CA 93202 (709)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES�EAR FIj01[D FIS 1mr D <br /> JOB ADDRESS J, _ <br /> .7Z t Q �' C7 7-tyD'QCITYPZIP c� 1 <br /> PARCELS APN yy ii--,�, <br /> OWNERNAME� ✓� —ADDMS�J sXit,t- <br /> CPIY/Z J� �? f} p PHONE 3 ��J <br /> ` CONTRACTOR /" " n� a/7Ud ' PHONES �6 -L 7 "Pax1/! <br /> CITYrLI <br /> GEOGRAPHICAL INFORMATION: COORDINATES X,v._ Y TOWNSHIP_ RANGE—SECTION <br /> TYPE OF WELL NPW WELL Q REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> i INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> 1 TYPE OF PUMP:W NEW ❑REPAIR H•P.--3?— DEPTH PUMP SET_ FP. FIRST WATER LEVEL <br /> 0 OUT-OP-SERVICE WELL ❑GEOTECHNICAL# 11SOIL BORING CJ DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIQN_ <br /> [3 INDUSTRIAL [3 OPEN BOTTOM WELL EXCAVAnONDI[AJ'L CONDUCTOR CASING <br /> DIA <br /> F DOMESTIC PRIVATE rgGRAVEL PACKISIZE_ WELL CASING TYPEI.V(?— WELL CASING DIA <br /> k O PUBLICIMUNICIPAL EJ DRIVEN GROUT SEAL DEPTH I 81) f. SPECIFICATION <br /> ❑IRRIGATIONIAG 24 H Fi N OTI C ETHER GROUT BRAND NAME <br /> ❑MONITORING <br /> R E Q U E ST E[D GROUT SEAL PUMPED: ❑NO <br /> Ep R /-\L—L- <br /> 0 <br /> LL❑CHRISTY BOX ❑STOVE PIPE I N S P CTf p N SCONCRETE PEDESTAL BY DRILLER: YES 13 NO <br /> APPROXIMATE WELL DE :3 a a <br /> PROPOSED CONSTRUCTIONIDRD.LING 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 ORDIANCFS,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: <br /> TITLE: DATE: <br /> i <br /> 14 <br /> I <br /> IN <br /> M <br /> M <br /> ""S' <br /> v.NT USE ONLY <br /> ! <br /> S�>L <br /> Application Accepted Be � DEPARTMate -I-A 1LO=ARa <br /> Grout Inspecti y Date d=LPumpInspected By Date <br /> Destruction Inspectio B _`--�Id y Date <br /> COMMEN'T'S: CSL O `F d9-6 W -7'D 3 i O F�. F-W 4J•'I- <br /> PE SC AMOUNT CHECK#/ RECEIVED DATE PERMITlSERVICE REQUEST M WELL iD# <br /> CODES INFO REMITTED BY <br /> Y <br /> t -- <br />