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WELL/PUMP PERMIT <br /> SAN JOAQUINY PUBLIC HEALTH SERVICES ENVIRONMENTSkALTH DIVISION*3E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 5852 W C,:7b Tla r k KoCt d <br /> PARCELSIZE/APPNQfimaDU rry/ZIP_ l_O,^d(_i r�"�✓`wL�14 14 <br /> OWNER NAME&j-W! jfiaY1 Vr U rr5DDRESS " Il14 W6-L1U) <br /> rry r v\ <br /> ondP <br /> cITY/zIP_LOC�I q�i242 <br /> PHONEE,Qq - ,3105y- o'l3_4P) <br /> CONTRACTOR NZAl FTY O IOCd OYI ADDRESS %Q1 N. 1 TUI )n LQre, _ <br /> CITY/ZIP L "ICJ O PHONE .r�CAVI '3k0ai - I <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y_ TOWNSHIP:�Iv RANGE 5F, SECTIIOON�,(,�� <br /> TYPE OF WELL: ❑ NEW WELL 13 REPLACEMENT WELL TL MONITORING WELL# NM\rJ L4-1' C7A <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. 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 12�I CONDUCTOR CASING DIA �I"I D <br /> SC.('lta(IAIfi <br /> ❑DOMESTIC PRIVATE *RAVEL PACK/SIZE-- WELL CASING TYPE 40 PVL WELL CASING DIA <br /> ❑PUBLICIMUNICIPAL ❑DRIVEN GROUT SEAL DEPTH 8 ++ SPECIFICATION Y <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> MONITORING GROUT SEAL PUMPED: - %YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: DYES ❑NO <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY_AIR ROTARY_AUGER X 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 NCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> SIGNED: n ~ <br /> TITLE: N S A DATE: Z+ c5P fPJC.VY��3PA' 99 <br /> COMMENTS: l21h d&--) &4_e k1..0(,2,Cr( <br /> PE SC AMOUNT CHEC RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# <br /> CODES INFO REMITTED CAS gy <br /> ��ei �f- 6�P tdl� P�- Oacg qb <br />