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WELL/PUMP PERMIT ^ SAN JOAQUIN COUNTY PUBLIC:HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION iJ 2 304 E.WEBER AVE., STOCKTON CA 95202 (204)468-3420 l NON-REFUNDASL PERMIT EXPIRES 1 YEAR FROM DATE .SUED JOB ADDRESS PARCELSIZE/APN �e9-a9i—O� C""ZD' OWNER NAME. �.Q mac- ADDRESS C1TYMP_ PHONE CONTRALTO ^^ jt t 'ADDRESS �A CITY2IPP�C ✓Y�CL PHONE GEOGRAPHICAL INFORMATIONt COORDINATES X Y,TOWNSHIP_ RANGE_SECTION TYPE OF WELL: ❑ A`EW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL N_ _❑077MR INSTALLATION: WELL SYSTEM REPAIR ❑CROSS- ONNECT REPAIR 13 VAPOR EXTRACTION WELL M _ r TYPE OF PUMP: d NEW �REPnIR H.P. � _ DEPTH PUMP SP.T�FT. FIR`,T WATER LEVEL ❑OCT-0F-SERVICE WELL ❑OEOTECHNICAI.N ❑SOIL BORING _ O DESTRUCTION: INTENDED USE TYPE OF WF.I.L CONSTRUCTION SPECIFICATION ❑INDUSTRIAL C OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WF.IJ.CASING DIA_ _ 1-1 O PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH _ SPECIFICATION- 0 JRRIGATIONIAG OTHER GROUT BRAND NAME_ . O MONTTORING GROUT SEAL PUMPED: ❑YES ❑NO 6 ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO APPROXIMATE WELL DEPTH PROPOSED CONSPRUCTJOIVDRILLING METHOD:MUD ROTARY_AIR ROTARY AUGER _CABLE OTHER_ I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN (o` JOAQUIN COUNTY ORDIANCFS,STATE S,A RULES AND REGULATIONS OF SAN JOAQUIN COUNTY, r\ SIGNED: TITLE.: i/tom J DATE., Q I I IA t— _ I _ O _ _ L1l -I t 4 .... DEPARTMENT USE ONLY s9 Application Accepted By Date C Grout Inspection Ry_ _ Date Pttenp lnspected ataSS/ Destmction Inspection By _ Date COMMENTS:_ PE SC AMOUNT CHEC RECEIVED DATE PERMIT/SERVICE REQUEST M WELL IDN CODES INFO REMITTED SH I BY � o ��qjf