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i" WELL/PUMP PERMIT 1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISIOI 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 • ` NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED JOB ADDRESS 6 �l ��14✓0�0 �. »`4 PARCEL SIZE/APNn L CITY/ZIP A144 r e c 1 X15 3 3 OWNER NAME^j/ ,Oell- S0 `(C &7 f, ADDRESS I rd 5- p .S. ��A t ktOH Py(q� CITY/ZIP /t'I r1 t PC w PHONE 5 �3 6 O -:32 `l 61 CONTRACTOR S e ADDRESS CITY/ZIP PHONE GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# 19 OTHER INSTALLATION: XWELL SYSTEM//REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# TYPE OF PUMP: ❑ NEW WREPAIR H.P. --L DEPTH PUMP SET FT. FIRST WATER LEVEL ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION ❑INDUSTRIAL }OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA KDOMESTIC PRIVATE 6 GRAVEL PACK/SIZE WELL CASING TYPE WELL CASING DIA ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION ❑IRRIGATION/AG OTHER GROUT BRAND NAME ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO APPROXIMATE WELL DEPTH_ 60 PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COU(NNT�—)Y ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. SIGNED: V GI/�n�11� TITLE: DATE: IAI i AI LH v �j _. I DEPARTMENT USE ONLY (� Application Accepted By \ lit ` Wt! Date 1 Area Grout Inspection By Date Pump Inspected B DateO Destruction Inspection By Dat, l COMMENTS:_ G-- ti sz 12 PE SC I AMOUNT 1,CHECK RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# CODES INFO REMITTED H BY