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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> ryryry{{{))) 304 E.WEBER AVE.. STOCKTONCA9520^- (:091468-3420 <br /> N-RE <br /> JOB ADDRESS L rj �.I�I{L�PC•Rti,I' �tP1R /S 1 'EAR FR01/i DATE ISSUED — <br /> PARCEL SIZEfAPN WWW��[b=_C) CrrrY121P-/ <br /> OWNER NAME \HHADDRESS. NI <br /> CiTY'2IP L—i. "ta � ADDRESS 'J .�/p--� <br /> CONTRACTOR ��// [['+�� Y fr(�:(,JA-0 / I" Ae_ JYv��j f <br /> CITY/ZIP b- �h 7r1 l PHONE-T"� l i / l L1C. 7 / L fIt4 Q <br /> GEOGRAPHICAL INFORNIATION: COORDINATES X_ Y_TOWNSIIIP_ RANGE—SECTION <br /> TYPE OF WELL: �❑l NEW'WELL ❑ REPLACEMENT WL 13ELMONITORING WELL✓x 13 OTHER <br /> qQ __..— <br /> INSTALLATION: W ❑ELL SYSTEM REPAIR CROSS-CONNECT REPAIR O VAPOR EXTR?.CTION WELL a <br /> r� t <br /> TYPE OF PUMP: ❑ NL•'W PRFPAIR H.P.` r DEPTH PUMP SET _FT. FIRST WATER LEVEL <br /> O OUT-OF-SERVICE WELL ❑GEOTECHNICAL p ❑SOIL BORING ❑DESTRUCTION: <br /> INTF,NDED USE TYPE.OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br /> DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE­ WELL CASING TYPE WELL CASING DIA---- <br /> 13 <br /> W❑PUBLIC/MUNICIP.AL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION <br /> Cl IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRiSTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑:NO <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY--AIR ROTARY_AUGER_C.-OLE_OTHER_ <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COU TY ORDIANCES,STATE <br /> LpAW.S,AND RALES AND REGULATIONS OF SAN JOAQVIN COUNTY. <br /> SIGNED: <br /> TITI.E: + <br /> I I i <br /> I <br /> • i <br /> - _ - - -- - _ <br /> n I <br /> I 1 I <br /> i.... .. .. . . _ ._ I i <br /> ..C-- <br /> D.PARTNIENT USE ONLY <br /> Application Accepted By,_. / L <br /> _._ �te. AreN__ <br /> / � r <br /> Gnwt[nµwcurw By — .._Umz_ Pump inspected BY'! <br /> 6—� <br /> ntc <br /> iDestruction ln�pccliiat B% _---- ........._ ./ Dare <br /> COMmy:.l,�ljii <br /> PE SC AMOUNT e-tq§gW RECEIVED DATE PI RMI'f.+S ERVICF REQUEST WELL IDu <br /> CODES INFO REMITTED CASH BY <br />