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WELL/PUMP PERMIT <br /> S QAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIII ES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESSf <br /> PARCEL SIZEIAPN /C�ITYIZIP_ <br /> OWNER NAME �7•j% t'dE`X J.�J2DRES5— , �L1 �:' ,/Cf� �-1 ?19C' <br /> CITY/ZIP ' '7 y� C. / �rxoNE <br /> CONTRAC'T'OR � Kk) �'1Y01 ra' � 422✓WDRESS <br /> CITY/ZIP /� kre"/tl �4 7PHONE_l d rr�C p <br /> GEOGRAPHICAL INFORMA'T'ION: COORDINATES X Y 'TOWNSHIP RANGE SECTION <br /> TYPE;OF WELL:A, NEW WELL ❑ REPLACEMENT WELL R MONITORING WELL 4 ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL 8 <br /> TYPE OF PUMP:., IEW ❑REPAIR 1-I.15. !'ap' DEPTH PUMP SET I,T. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICCE WELL ❑GEOTECHNICAL 4 ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION.SPECIFICATION <br /> ❑OPEN BOTTOM WELL EXCAVATION DIA T CONDUCTOR CASING DIA <br /> " OMESTIC PRIV FE RAVEL PACK/SIZE WELL CASING TYPE WELL CASING DIA <br /> AL ❑DRIVEN GROUT SEAL DEPTH <br /> SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> _`_'_'C UT SEAL PUMPED: . a cs ❑No <br /> ❑MONITORING ��.��J�- � , <br /> ❑CHRISTY BOX ❑STOVE PIPE <br /> fq = � {r�-yg`-{� �n q CONCRETE PEDESTAL BY DRILLER: ❑YES O <br /> APPROXIMATE WELL DEPTH.__ i.-� <br /> PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY�AIR ROTARY AUGER CABLE — OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL 13E DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COU�I/ORDY ANCE T TE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: <br /> TITLE: ' .- DATE: <br /> L <br /> { ---- <br /> 1p <br /> -- C <br /> C <br /> 1 <br /> --_ --�� <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Dale Area <br /> f� PAY1VET <br /> Grout Inspection ate r Or' Punap fuspectcd By DfjE,, CZj_\ EE) <br /> DesICUCLiall InSpection B,y�y ^�Dale G — 3 yrl <br /> COMMENTS:_ <br /> L� 1 1 JL(`LG • J CUUU <br /> SAN JOAQUIN COUNTY <br /> R 51 if�p H SERVIGES <br /> ENVIRONMENTAL HE11l.T "I <br /> PE SC AMOUNT IECIC#! RECEIVED DATE PERMIT/SERVICE:REQUEST 0 WELL ID#1 <br /> CODES INFO REMITTED CAS'I1 BY <br /> PLATE 13 <br />