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WELL/PUMP PERMIT , SAN 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 `-)499 C ��lT�t-12. \ cnc)c�> %0 11 SAC. �f/.. --04,05 PARCEL '2� CTTY/ZIP "MV Q> - OWNER NAME M1'��KC ��iQ4eC-I�ADDRESS (OI I 'A�-k_0 F Q�2 CITY/ZIP Loy t PHONE_ ZQ� 339 "d�33 CONTRACTOR ADDRESS SAMA CITY/ZIP PHONE GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE l I SECTION TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# )KOTHER 6ctT O $ V,r� INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# '7'uRB/tiE T PE OF PUMP: ❑ NEW ❑REPAIR H.P. 30t,Q DEPTH PUMP SET FT. FIRST WATER LEVEL T-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: NTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION ❑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 SPECIFICATION XIRRIGATION/AG OTHER GROUT BRAND NAME ❑MONITORING 24 1H R N(DT(C;f_— GROUT SEAL PUMPED: ❑YES ❑NO ❑CHRISTY BOX ❑STOVE PIPE F. �_ CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO APPROXIMATE WELL DEPTH 1r--j S P I_C-'T I tD N S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR 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 ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. SIGNED: lny\� -F_- TITLE: OW ne Ag- DATE: I DEPARTMENT Application Accepted By Date �`/ Area Grout Inspection By Date Pump Inspected By Date Destruction Inspection By SAN 30AEOA jN —Date COMMENTS: 6j- fN �'� `Iwr—f A.(.t. ems( t--' 4 7- e'P-1 co PE SC AMOUNT CHECK# RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# CODES INFO REMITTED SH BY 1 q3 1 S� U Z