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• APPLICATION FOR WELLIPUMP PERMIT • PAYMENT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES RECEIVED <br /> ENVIRONMENTAL HEALTH DIVISION F�>; 2 1 1596 <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 <br /> (209) 4883420 SAN JO;'•,4Ull;CUUNTY <br /> PUBLIC HEALTH SERVICES <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH DIVISION <br /> (CBmplets In Triplicate) <br /> APPLICATION I6 HERE BY MADE TO THE SAN JOAGUI COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TRUE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESSOR APNa/Lr 1— CO KN Is6, VAES'r `f FKF-SHO /SLC CRY (./S�-(/I�c(I�5' 1/VN/J ;7 PARCEL SIZF/APNe 9-?? /4COf 9j <br /> (('`� ACr_ADDRESS�/ F •�• Lr L- %/NIFL I//I. S�rEgsPlwN. 7S3 yY <br /> OWNER'S NAMBSToc Kroll/ lUnJr�I IE•b JC1'FOOI <br /> y/ '1 N HDV1T'b,V 4AI 40V c''s :3 <br /> COMRACTOfl��E/L,ID �TwG�/ALMJ 1`4130C.0 /NL AODRE68hC 1 1 IICA�e(O�DL/ %10NEi b � ��/ <br /> SUBCONTRACTOR /V//'- I ADDRESS UC:F PHONE• <br /> TYPE OF WE MP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONTORNO WELL i ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J <br /> ❑Naw❑Repair N.P. DEPTH PUMP SET----YT- FIRST WATER LEVEL O <br /> (TYPE OF PUMP) . <br /> ❑ OUT-Of-SERVICE WELL ❑ GEOPNY6ICAL WELLi � SOIL11B1OROINO Spn7l°L/N 6 Fb.L B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION CPECIFICATIONa /1 A <br /> ❑ INDUSTRIAL ❑OPENBOTTOM DIA.OF WELL EXCAVATION �/.S DIA.OF CONDUCTOR CASINO D <br /> ❑ DOMESTIC/%OVATE ❑GMVEL PACK/SIZE TYPE OF CASING/STEEL TVC DIA.OF WELL CAGING D <br /> ❑ MBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION <br /> ❑ IRNGATIONIAC 11 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME SVIL CU7T/NhJ f <br /> ❑ MONITORING GROUT SEAL PUMPED: Ely. [IN. CONPFfOEWVLLFR:❑Vw [IN. S <br /> LOCKING CHESTER BOX/STOVE PIK N N! 0 r, t t L 1 <br /> APPROX.DEPTH LOLJ BOE- 1"RRT /4sr- <br /> PROPOSED CONSTRUCTIONNmWNO METHOD: MUD ROTARY AIR ROTARY AUGER�_CMLf OTHER CFJ4tT S / <br /> a <br /> 1WELLS FARGO BANK0 3 6 31 <br /> NEIL 0. ANDERSON &ASSOC., INC. 76M PACIFIC AVE. <br /> 22 NORTH HOUSTON LANE STOCKTON,CA 95207 <br /> LODI,CALIFORNIA 95240 <br /> (209)367-3701 11.24 567 <br /> 2/21/96 <br /> PAY <br /> OROEO H San Joaquin County Public Health Services $ **234.00 <br /> Two Hundred Thirty-Four and 00/100**++***************+++************ DOLLARS <br /> San Joaquin County Public Health <br /> 445 N San Joaquin St. <br /> PO BOX 2009 <br /> Stockton, CA 95201 <br /> I <br /> MEMO APN 163-060-09- S9566 O. <br /> _a <br /> C <br /> 3C1c.IyC.,/ u 1;'_J� T:zO'c't') 4tr/'!_ <br /> tf/y <br /> r/C 14 r1 S <br /> DEPARTMENT USE ONLY <br /> ApplIcation Acc IM BY Are. <br />