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��1 WELL/PUMP PERMIT <br /> I I <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVLWEI, <br /> 304 E.WEBER AVE- STOCKTON CA 93202 (209)4W3420 <br /> ._ : <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS F7 C�� 0R ,h N C: _ <br /> PARCEL SIWAPN Z-r/ ( ,S 3ZV4"", <br /> OWNER IiAMEA/�M' L ��•1 ADDRESS <br /> CTTYMP ��{lcXy J' l/�'�'r' / PRONE <br /> CONTRACTOR-# y,,//��/`l CAL!:S D1L/LC th ADDRESS A J� ` <br /> CTTYlL�� L�aLqd lL/ rC PHONE �'� 7Z <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y_TOWNSHIP_ RANGE_SECTION <br /> TYPE OF WELL: NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> i INSTALLATION: ITWELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL <br /> # <br /> TYPE OF PUMP: CP4IEW 13REPAIR H.P. Z " 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 DLA <br /> DOMESTIC PRIVATE 1_4CRAVEL PACK/SIME_ WELL CASING TYPE `li WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUTSEALDEPTH 04 /+ SPECIFICATION <br /> ❑IRRIGATION/AG 2L4 H R N OT1 CSR GROUT BRAND <br /> ❑MONITORING R E Q U ESTE 1E OUT sEAL PUMPED: R:�ES ❑NO <br /> FOR ALL <br /> ❑CNRISTY BOX ❑STOVEPIPE / l N S R E CT!Q T�+gCRETE PEDESTAL BY DRILLER: ChqMS El NO <br /> APPROXIMATE WELL DEPTH Z Vy ' <br /> PROPOSED CONSTRUCTION/DRILLING METHOD:MUD ROTARYS,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 ORRD�IAANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED:., eL A., I <br /> TITLE: ( 0LIA-s_i'L —2-7' <br /> c <br /> DATE: -� <br /> I <br /> C <br /> I <br /> I <br /> I <br /> i <br /> i <br /> Al I <br /> uNPIL <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Datea v Z A. <br /> Grout Inspection By Dater,-3'OZPump Inspected By Date <br /> Destruction Inspection B} ate <br /> COMMENTs�, A6�(sO,Iyc-ffOc�4RvtcT N5 �1SJ1,�A <br /> PE SC AMOUNT CHECK#/ RECEIVED BATE PERMIT/SERVICE REQUEST S WELL IDN <br /> CODES INFO REMITTED BY <br /> . 00 2 7 <br /> 05� d 60 <br />