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:7 6, WELL/PUMP PERMIT _ '` <br /> .t"^ SAN JOAQUIN NTY PUBLIC HEALTH SERVICES ENVIRONMEN - <br /> KT N A 95202 209 468-3 <br /> 04- 0 <br /> 304 E.WEBER AVE.,' STOC 0 C { ) <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED _ 4 <br /> JOB ADDRESS <br /> PARCEL SIZFJAPN •l <br /> rrL` h CITYIZIP <br /> 1 • L n1/ SLY <br /> OWNERNAMEC ADDRESS l) <br /> Z,�I � �J C. :) _ 1 (., <br /> CITY("LIP J ' PHONE J ✓ <br /> ICONTRACTOR��_ L Y20 ADDRESS — <br /> CITY/ZIPf <br /> .i� J426-s .!it f C r PHONE, •, 41 <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: /NEWWELL ❑ REPLACEMENT WELL 0 MONITORING WELL# ❑OTHER <br /> r i <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE QF PUMP: b NEW (3�REPAIR H.P. DEPTH PUMP SETS , 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 CONDUCTOR CASING D'IA <br /> DOMESTIC PRIVATE H GRAVEL PACIUSIZE WELL CASING TYPE <br /> WELL CASING DIA v <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTHS' C "t SPECIFICATION <br /> ❑IRRIGATION/AG 24.H R OTHER GROUT BRAND NAME C <br /> ❑MONITORING R E[�U E Pq O�ttO�L PUMPED YES ❑NO <br /> F� ST NEC E PEDESTAL BY DRILLER: (9 YE5 Q NO" <br /> ❑CHRISTY BOX ❑STOVE PIPE R /�LC� <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTION/DRIILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> jl <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN lR7 T D <br /> JOAQUIN COUNTY ORDIANCES,STATE LAWS,AND RULES'AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: �•< <br /> Z `�" <br /> TITLE: ;7�1.� J✓`I(� _ _ DATE: ENVIRONMENT - <br /> �.. <br /> AffH <br /> i.. a <br /> O V II <br /> 3 � baa, <br /> r CD Yd <br /> ,s� f <br /> `1 <br /> grce�7gxsro " <br /> -- <br /> ��., —DE-PAsIT-tS41 1f? FtSF <br /> Application Accepted By_,�� � � `1" � s - ��� `_ _` Datc <br /> Grout Inspection By Date Pump•dnspected By Date 4 <br /> Destruction Inspection ByD to <br /> COMMENTS: . \ 'C� ✓ LYS'� U 1 ( . J �. {"E" I`' I t� <br /> ('0( l 0 C' <br /> PE SC AMOUNT RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# <br /> CODES INFO REMITTED CASH BY i <br /> d &,'f—IC-1 �� <br />