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WELL/PUMP PERMIT <br />e jA41ekQ IIN COUNTY PUBLAC HF.AI.TH SERVICES ENVIRONMENTAL HEALTH DIVISION <br />77�� ti <br />304 L. WEBL•R AVE., STOCKTON CA 952(12 (209) 469-3420 <br />�2� <br />`�;sL- ' /I ls` NpY-KJ F 1JNUARLE PERMIT EXPIRES 1 YEAR FROMDATE ISSUED <br />ivol <br />` JOB` ARE- s_ <br />PARCEL 51Z&APN�� <•� • C CITY"ZIY <br />4: OWNER NAME �� r 5i�' �: �s. CO„_ADDRLSS_ �a <br />CITY/7IP-_ PHONE. <br />�R1N ►USSAFI' <br />CONTRACTOR_. 1 / ._ ADDRESS <br />crrYr7m +t C c►�l,'c. �} 5 a c' ( PI10NWT C% <br />CE(X;RAPHICAL 1NFOR1\IATION: COORDINATES X_ Y TOWNSHIP_ RA N(;E _. SECTION <br />TYPE OF WF.LI.: ❑ NEW WF.I.L Cl RFPT.,ACEMFNT WELL ❑ MONITORING WELI. # <br />❑ OTHF.R <br />INSTALLATION: D WELL SYSTENI REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACIION WfiLI. #! <br />TYPE OF PUMI': ❑ NEW Cl REPAIR H.P._ _ DEPTH PUNIP SET _-.___ _FT. FIRS'r W`ATL•R LEVY LL -_.. _ <br />❑ OUT -OF -SERVICE WELL AGEOIL CIINICAI, 4 3 ❑ SOIL BORING _- )d DLSTRUCTION:yc�c� • �� <br />2 kV &\ kySrl, l l cc:.�Ai r-fS <br />INTENDED USE: TYPE OF HELI. CONSTRUCTION tiPF:CIFICA'TION <br />❑ INDUSTRIAL ❑ OPEN 110'1TOM W'F.LL EXCAVATION DIA CONDUCTOR CASING DTA <br />O DOMESTIC PRIVATE ❑ GRAVEL PACKISIZE WELL CASING TYPEWELL CASING DIA <br />Cl PUBI-IC/.\,IUNTCIPAL ❑ DRIVEN <br />❑ TRRIGATIONIAG 24 "R N OT I C E <br />❑ MONPrORING R E Q U E ST E ED <br />[I ('HRISTY BOX ❑STOVE- PIPE. FOR ALL <br />I N S P EC�I O N S <br />APPROXIMATE WELI,11EPTiT_7S X00 <br />GROL'l SEAL. DEPTH- ._ _ SPECIFICATION - <br />OTHER GROUT BRAND NANIE <br />GROUT SEAL PUMPED: ❑ YES ❑ NO <br />CONCRFTF PEDESTAL AY DRILLER: ❑ YES ❑ N(1 <br />PROPOSF,D CONS1'RUC:TION/DRTLLIN(i.NIFiHOD: MUD ROTARY_ __ AIR ROTARY AUGER CABLE OTHER <br />ITEREBY C:ERTIFV'I'IIAI' l HAVE PRE:P:A.RE:DTHIS APPLICATION AND THATTHE WORK WILL BE: DONE: IN ACCORDANCF. WI'T'H SAN <br />JOAQUII\ COUNTY ORDIANCES, STATE LAW'S, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />SIGNED .c, L -Y (71. — - - - <br />ms)I- - - k- - r <br />