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Pun P <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br />NON-REFUND I ABL PERM <br />d <br />IT XPIRES I YEAR FROM DATE ISSUED Obq CilLptat ha <br />PARCEL SIZE• ny.-"ivior) n q5;115 <br />OWNER NAM Ili 1 IMIMNI. * <br />D . PH IO INIEEss4a h7g. 1 "(C)C°(° ....1LrOM2a1rktitR.REss U)11643CVt9,a <br />11411-41-u #04, plloNar)?(?(51-10 <br />GEOGRAPFIICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION TYPE OF WELL: 13 <br />NEW WELL CI REPLACF-MENT WELL CI MONITORING WELL # CI OTHER INSTALLATION: 0 WELL SYSTEM REPAIR CI CROSS-CONNECT REPAIR <br />'E I NEW 0 R AIRO ; I' /la DEPTHy <br /> /44"IVSOIL B <br />CONSTRUCTION SPECIFICATION <br />WELL EXCAVATION DIA CONDUCTOR CASING DIA <br />WELL CASING TYPE WELL ING DIA <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AU <br />.JOAQUIN COUNTY ORDIA CES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN CO DONE IN A lerN LAN HIS APPLICATION AND THAT THE WORK <br /> 0TH <br /> HEREBY CERTIFY THAT I HAVE PREPARED T <br />Date <br />COMMENTS: JUL 2 7 2 <br />SC <br />INFO DATE PERMIT/SERVICE REQUEST <br />..2L 95 co P:35 <br />(C-HEAC <br />7b-7/61D <br />AMOUNT <br />RESif51 <br />PE <br />CODES <br />139:° <br />RECEIVED <br />BY <br />'7,406 Lo <br />WELL IDa <br />SAN JOAQUIN COUNIY <br />PUBLIC HEALTH SERVICES, <br />ENV1RONMEN i AL HEALTH DIVIAIi <br />SIGNED: <br />TITLE: 1e ftZI1 <br />DATE: 7/Aida) <br />.0. <br />i.17 as. (V - ',or; • -• <br />mt. <br />DEPART NT USE ONLY <br />Application Accepted By .— <br />Grout Inspection By Dale Pump hiilEG <br />Destruction Inspection By <br />Date <br />bG <br />304 E. WEBER AVE., STOCKTON CA 95202 (209) 468-3420 <br />JOB ADDRESS <br />CITY/Z <br />CONTRA <br />CITY/Z1 <br />0 VAPOR EXTRACTION WELL # <br />INTENDED USF, <br />0 INDUSTRIAL <br />,)OMESTIC PRIVATE <br />0 PUBLIC/MUNICIPAL <br />O IRRIGATION/AG <br />0 MONITORING <br />0 CfiRISTY BOX 0 STOVE PIPE <br />APPROXIMATE WELL DEPTH_ <br />TYPE OF WELL, <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN GROUT SEAL DEPTH <br />24 H R NJ OT I C TITER GRO NAME REQUESTED <br />GROUT SEAL FOR ALL <br />INispEcTiCoNIONCRETE PE R: <br />I ; WA EVEL <br />DES 0 : <br />TAO