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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 ,� ^5 D0Z <br /> /�Jl G <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS ml .� !'� <br /> PARCEL SIZFJAPN . CITY/ZIP _�I�J �I.N � r7' C,J <br /> OWNER NAM AtI&I ZMADDRESS '7�7 7 <br /> CITY/ZIP - PHONE ©!' / �L / lam <br /> CONTRACTOR I► 'It ADDRESS ^d Roy /(/ <br /> z — <br /> CITY/ZIP PHONE 6�(l' '1�2 C, <br /> GEOGRAPHICAL INFOORRMATION: COORDINATES X Y TOWNSHIP RANGE SECTION <br /> TYPE OF WELL: W NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP: ANEW ❑REPAIR H.P. DEPTH PUMP SET_/_4�—dFT. FIRST WATER LEVEL l <br /> ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ` N <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIAL CONDUCTOR CASING DIA <br /> OMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE- WELL CASING DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH�0 SPECIFICATIONS <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME �r A a— <br /> 24. <br /> ❑MONITORING _ _ GROUT SEAL PUMPED: & ES ❑NO <br /> ❑CHRISTY BOX ❑STOP "'" <br /> VEE PIPlg=k__A =A �r.'xL_� CONCRETE PEDESTAL BY DRILLER: 6-YES 11 NO <br /> APPROXIMATE WELL DEPS I(g" ^ f i c r <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY C 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 ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> __xSIGNED: 7���►. <br /> TITLE: DATE: / CI r✓ <br /> —7777.,r <br /> rArcc;ri, i , DETAIL <br /> 5.06 ACRES I <br /> ORES <br /> SCALE 4on <br /> Flo <br /> :wi,:...... <br /> PIS <br /> A SCVAR <br /> , 6 S <br /> .. 3w <br /> I I <br /> , v <br /> Application Accepted By V�� y Da J Area 1 v <br /> 9 1t_I a <br /> Grout Inspection By ate/ �I Pump Inspected By <br /> Destruction Inspection By to <br /> DEQ <br /> COMMENTS: <br /> PE SC AMOUNT <CHEE.Kj0K RECEIVED DATE PERMIT/SER REQUEST# WELL ID# <br /> CODES INFO REMITTED H BY <br /> c0a.� 2dQ 0024 8S <br /> 40 <br /> p 0 52 <br />