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WELL/PUMP PERM. r,S N JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED JOB ADDRESS nC _/O /'lro �K��/'�— PARCEL SIZE/AP''N""�� CI^QS CITY/ZIPc '�OO OWNER NAME;TC I'rrL O Z&A4I rl 6 ADDRESS '7`Z C 144ra-.. 4222 CITY/ZIP + CQ/In�� 1$_ZZ AONE CONTRACTOR I 1 r(!I 4 ADDRESS CITY/ZIP ` LPI r PHONE 5--2 2 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# ❑SOIL BORING ❑DESTRUCTION: INTENDED USE TYPE OF WELI. CONSTRUCTION SPECIFICATION ❑INDUSTRIAL )PEN BOTTOM WELL EXCAVATION DIA 1112 CONDUCTOR CASING DIA TAOMESTIC PRIVATE >�GRAVEL PACK/SIZE WELL CASING TYPE WELL CASING DIA ❑PUBLIC/MUNICIPAL •� ❑DRIVEN GROUT SEAL DE SPECIFICATION ❑IRRIGATION/AG 2 4 H R r\1 C)i I C�E OTHER GROUT BRAND NAME GUS/O ❑MONITORING f`E C)U E FEE ID GROUT SEAL PUMPED: 1 YES ❑NO FC)F:� A\1 i 1 ❑CHRISTY BOX ❑STOVE I£��p 1H.—r-I �V CONCRETE PEDESTAL BY DRILLER: ❑YES 'NO APPROXIMATE WELL DEPTH PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARYXIAIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY OR//144,2,d4/ D/I�A� C NCES,,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. SIGNED: L(/;(IL `/ Y 4,2, 4 ��** TITLE:_ h\) y DATE: otk 4L, UIN CO _62LI HE LT Aj DEP RTMENT USE ONLY Application Accepted By Date _ 2Area U � Grout Inspection By / G Dat ump Inspected By �/}�L�GIiC% Date Destruction Inspection Date COMMENTS: _ lij ,ZB c PE SC AMOUNT ,CHECW RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# CODES INFO REMITTED FI BY (,l3 1fU 2 3 ��