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WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION kyr 304 E.WEBER AVE., STOCKTON CA 95202 (209)468-3420 `, � NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 70B ADDRESS PARCEL SIZE/APN CITY/ZIP �y OWNER NAME $ ADDRESS_ a C CITY/ZIP ILA G ,�+ !,��P�H�ONE CONTRACTOR -0�1� l 1 ,C "'�bDRESS� CITY/ZIP (3C& T0, gs3 D PHONE (-a V�1� �$ 1 "! GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP RANGE SECTION TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER INSTALLATION: rELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# n TYPE OF PUMP: NEW ❑REPAIR H.P. 1 l� DEPTH PUMP SET FT. FIRST WATER LEVEL V ❑OUT-OF-SERVICE WELL ❑GEOTECHNICAL# ❑SOIL BORING ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA ?1)QMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE S �L WELL CASING DIA _ ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION ❑IRRIGATION/AG 24 HR OTHER GROUT BRAND NAME REt�UES-1-f= 11 MONITORING FC) n /–\I i— GROUT SEAL PUMPED: ❑YES ❑NO ❑CHRISTY BOX ❑STOVE PIPE I N GS P E(:-,--F Y(:–)N S CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO APPROXIMATE WELL DEPTH J 0 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 C UNTY ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. SIGNED: TITLE: DATE: \ 4477 I.. iV )r l DEPARTMENT USE ONLY Application Accepted P \ Date – –U � Area .Ce Grout Inspection By Date Pump Inspected By Datek�� Destruction Inspection By Date COMMENTS: PE SC AMOUNT / RECEIVED DATE PERMIT/SERVICE REQUEST# WELL ID# CODES INFO REMITTED ASH BY