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Puff) <br />WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br />304 E WEBER AVE., STOCKTON CA 95202 (209) 468-3420 <br />Nf NON-REFUNDABL PERMIT,EXPIRES I YEAR FlIOM DATE ISSUED <br />JOB ADDRESS I (OM ao_RDAL; hod . <br />PARCEL SIZE/ <br />frIpi CiA4 ct9..15 <br />DRESS hcw z4 (ao(4) <br />PEONE 4-19 <br />RESS 9-a) ICOIC tree-A0/ <br />PH°14CITR 6/(5/-5 /0 <br />AMOUNT <br />RFAIsii33.D <br />romocio DATE - PEANUT/SERVICE REQUEST # <br />wPocyz ticpi 5 2to P:35 a) <br />SIGNED: <br />TITLE: <br />Mir <br />,M•••• <br />ib <br />Application Accepted By <br />Grout Inspection By <br /> <br />Destruction Inspection By <br />COMMENTS: <br />SC <br />INFO <br />Date <br />RECEIVED <br />BY <br />"106; <br />Pump lifilEte* <br />SAN JOAQUIN COUN I <br />PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVIGION <br />Date 5.-1C/a . <br />Date <br />WELL ID* <br />PE <br />CODES <br />Lt30 <br />1 <br />DEPAR I NT USE ONLY <br />JUL 2 7 200 <br />Date <br />AIRO <br />tL .JOAQUIN COUNTY ORDIA CES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN CO DONE IN A le" AN <br />I HEREBY CERTIFY THAT I-HANIE PREPARED THIS APPLICATION AND THAT THE WORK <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY_ AIR ROTARY _ AU <br />INTENDED USE <br />0 INDUSTRIAL <br />DOMESTIC PRIVATE <br />0 PUBLIC/MUNICIPAL <br />0 IRRIGATION/AG <br />0 MONITORING <br />0.CHRISTY BOX 0 STOVE PIPE <br />APPROXIMATE WELL DEPTH <br />INSTALLATION: <br />• • I <br />TYPE OF WELL: 0 NEW WELL <br />GEOGRAPHICAL INFORMATION: COORDINATES X <br />0 WELL SYSTEM REPAIR <br />NEW <br />TYPE OF WELT, <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />CI DRIVEN <br />0 REPLACEMENT WELL 0 <br />GROUT SEAL DEPTH <br />24 HR NJcDTIG THERGRO <br />REQUESTED/ GROUT SEAL FOR ALL <br />I N.ISFEQTIDNJS ONCRETE PE <br />0 CROSS-CONNECT REPAIR <br />Y TOWNSHIP RANGE SECTION <br />DEPTH I' <br />SOIL B <br />MONITORING WELL # 0 OTHER <br />CONSTRUCTION SPECIFICATION <br />WELL EXCAVATION DIA__ CONDUCTOR CASING DIA-____ <br />WELL CASING TYPE <br />0 VAPOR EXTRACTION WELL # <br />—G171?2-71/4 LbeRWAON: 71)141751' <br />NAME <br />WELL ING DIA <br />yTEST) NO4e, <br />'E *F