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n WELL/PUMP PERMIT PAYMENT <br /> SAN JOAQUIN COUNTY PUBLIC-HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 RECEIVED <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED •n .. <br /> JOB ADDRESS 16042 E. Baker .Rd. <br /> SERgOUQ <br /> AN JOAQUIN COUNTY <br /> PARCEL rp 11 PUBLIC HEALTH S <br /> ALM DIVISION <br /> OWNER NAME Charley LacjOlilarSinOADDRESS 16042 F. AakPr Rt3 <br /> crrympLindenPxoNE <br /> coNTRAcroRPurviance Drillers,.inamss. P.O.Box 6.4 <br /> myrap Linden. Ca 95236 PHONE ` <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y_TOWNSHIP_ RANGE_SECTION <br /> TYPE OF WELL: ❑ NEW WELL. ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR. ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: YFWW &ILEPAIR H.P. 9 DEPTH PUMP.SET___120L Fr. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ❑INDUSTRIAL ❑OPEN BOTTOM X �TatCONDUCTOR CASING DIA <br /> fI]DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE_ GRRUT�E/A�I )9 <br /> WELL, ' �am.djt 9rV'_ ASING D <br /> IA <br /> er13 PUBLIGMUNICIPAL 13 DRIVEN C4 SO <br /> WQ ( <br /> ❑IRRIGATION/AG O GRP@"" *r0d a <br /> 13MONITORING GROUT SEAL r NO <br /> //���� <.i�P <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLS ERR: 0 ! ❑NO ! <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTION/DRILLING METHOD:MUD ROTARY_AIR ROTARY_AUGER 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 ORDJANCES ATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. I <br /> i <br /> SIGNED:��' <br /> TITLE:_ Corporate Secretary DATE: 9/5/00 <br /> of <br /> I <br /> I <br /> f <br /> . I <br /> i <br /> I <br /> �I <br /> �I <br /> I <br /> I <br /> DEPARTMENT USE ONLY — '-- fj�f� <br /> Application Accepted By Date t/v Area <br /> Grout Inspection By Date Pump Inspected By Date <br /> Destruction Inspection By Date <br /> COMMENTS: <br /> PE SC AMOUNT CHECK# RECEIVED DATE PERMIUSEiNICE REQUEST# WELL ID# <br /> CODES INFO REMITTED BY <br /> s'a �a ,?/qob <br />