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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVIS <br /> 304 E.WEBER AVE.. STOCKTON CA 95202 (209)468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS '0 E AAL1am AN t _ <br /> PARCEL SIMAPNZ .5 Z mr2IP <br /> OWNER NAM t NI & ADDRESS Z/, <br /> CITY/ZIP sr�rr PHONE <br /> CONTRACfOR14 J_',4irr-� ®IL/I L I ADQ <br /> DRESS �7 ) <br /> IT <br /> CYIZ[FV.7/� PHONE �, =y�[✓! <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y TOWNSHIP RANGE—SECTION <br /> TYPE OF WELL: NEW WELL O REPLACEMENT WELL O MONITORING WELL# _0 OTHER <br /> INSTALLATION: IT WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR O VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: CNEW 13 REPAIR H.P._ DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> 13 OUT-0F-SERVICE WELL 0 GEOTECHNICAL# D SOB,BORING 0 DESTRUCTION: <br /> INTENDED USE TYPE OF WELL ONSTRUCTION SPECIE CATION <br /> 0 INDUSTRIAL 0 OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> DOMESTICPRIVATE ,GRAVEL PACKISaE WELL CASING TYFE `U WELL CASING DIA _ <br /> ❑PUBLIC/MUNICIPAL 0 DRIVEN GROUT SEAL DEPTH 100 SPECIFICATION <br /> 0 IRRIGATION/AG 24 F A FJ -F1(:n eeR GROUT BRAND NAME_ce&., <br /> 0 MONITORING R Fes,Q U F—'::; E KOUT SEAL PUMPED: BES 0 NO <br /> F=-OR ALL <br /> ❑CHRISTY BOX 0 STOVE PSE I N S P' C T I OCR''TE PEDESTAL BY DRILLER: LPfq_S 0 NO <br /> APPROXIMATE WELL.DEPTH_ Gr Gy <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 BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY�OOR[DII,A�NCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: 4_7'_ z/�l� <br /> Cil <br /> TITLE: DATE: <br /> I <br /> C • <br /> FT: <br /> EPARTMENT USE ONLY <br /> Application Accepted By -j)-_54a v Z Area <br /> Grout Inspection By Date' `OZ-Putnp Inspected By Date <br /> Destruction Inspection B Date <br /> COMnt EN;'SG��.o sO�kJc,� roc��%AgiRICNO AL 05 �SAt�Ks1A�D <br /> PE I SC AMOUNT CHECK#/ RECEIVED DATE RVICEREQUES WELL ID# <br /> CODES INFO REMITTED BY <br /> vG� 36-3 3s oQ Z 7 <br />