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WELL/PUMP PERMIT SAN JOAQUIP LINTY PUBLIC HEALTH SERVICES ENVIRONMEN HEALTH DIVISION If ,4 E.WEBER AVE., STOCKTON CA 95202 (209),,---3420 (I b NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS �S—()� /!/r 411V14 �(�_ PARCEL SIZFJAPN CI—TY/ZIP OWNER NAME t2ADDRESS CITY/ZIP 3� PHONEI CONTRACTOR� ADDRESS 42gdA!5 Ee !/ /Y/e7Z� f _ CITY/ZIP .PHONE _�� GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# TYPE OF PUMP: ❑ NEW ❑REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# lFrIZOIL BORING j— ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION rr ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA� CONDUCTOR CASING DIA ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE /��,WELL CASING DIA ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH 66 PECIFICATION ❑IRRIGATION/AG 24 HR it?L7 i C E OTHER GROUT BRAND NAME r'P.�d.✓/ ❑MONITORING R F C)ti i_S 1 E ED GROUT SEAL PUMPED: ❑YES Cf"iI0 FC)F3 ALL ❑CHRISTY BOX ❑STOVEI Vq S P E C_F i C N S CONCRETE PEDESTAL BY DRILLER: ❑YES UKO APPROXIMATE$WF4_+4�EPTH PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE LL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. SIGNED: /� y �7 TITLE: e!!57 DATE: --- DEPARTMENT USE ONLY Application Accepted By Date U Area(�j..� Grout Inspection By Date Pump Inspected By Date Destruction Inspect By Date COMMENT / Z "-✓� PE SC AMOUNT CHECRECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# CODES INFO REMITTED CAS BY