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WELL/PUMP)'r ttMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE.. STOCKTON CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS �- S ; /V (/V r�.V <br /> n <br /> PARCEL SIZFJAPN �/��, ry � / CITY= L 110 <br /> i <br /> OWNER NAM 60tL,L' �L�A4QCA ADDRESS I4-L <br /> CITY/ZIP Z)JOJ PHONEell '��,,,,/ r� <br /> CONTRACTO _Gl�H CrJIZy(7sr LA f ADDRESS �i/�� 61T I f <br /> CfTY/ZZIPjAJC0� �t2l �_& PHONE 1 n]Y" / <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP_ RANGE_SECTION <br /> TYPE OF WELL:X NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATIONLL3°fSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOLR/EXTRACTION WELL# <br /> TYPE OF PUMP: )KNEW ❑REPAIR H.P. DEPTH PUMP SET ` / 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 DIA <br /> OMESTIC PRIVATE GRAVEL PACK/SIZE WELL CASING TYPES WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH I 00_. SPECIFICATION <br /> ❑IRRIGATION/AG 24 HR NC) I C FTHER GROUT BRAND NAME_Ca f1;ff <br /> REQUESTED <br /> ❑MONITORING FOR ALL GROUT SEAL PUMPED: YES 13NO <br /> ❑CHRISTY BOX ❑STOVE PIPE I P E CTT i O N_Cq)NCRETE PEDESTAL BY DRILLER: )KYES ❑NO <br /> APPROXIMATE WELL DEPTH 3 3 <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY X 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,,SS�T/AAJTE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: ✓ J .A�T�"' t'� <br /> TITLE: DATE:3 <br /> 1 7 <br /> i <br /> 4# <br /> _ c <br /> ._..Af)h.1FtGi Foi i icu <br /> DEPARTMENT USE ONLY <br /> � � 3a/ <br /> Application Accepted By D to Area9 <br /> Grout Inspection By Date 8'0 4mp Inspected By Date L 3-U <br /> DaWctionIns yo y Date <br /> 290/ <br /> COMMENTS: Af o p.+1 EARson+ - c u ��, •co rr -z� r <br /> PE SC AMOUNT CHECK#/ RECEIVED DATE PERMIT/SERVICE REQUEST# WELLID# <br /> CODES INFO REMITTED BY <br /> -TV3D <br /> w O -aaS Ll <br />