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WELL/PUMP PERMIT %J R I U I i <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br />304 E. WEBER AVE.. STOCKTON CA 95202 (209) 468-3420 <br />NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />JOB ADDRESS 14terseel ea of Willow (A)4V clod $ fuoiq iaL�uaLd <br />PARCEL SIZE/APN GTY 52?AE7 CITY/ZIP q5376 <br />OWNER NAMI� CHFURaN ENutmoA/Hfa L""' ADDKESS 600( 6Otli ev Oem bu a S <br />S- <br />j14NA-6 E N.FN T CoA AAA/y <br />CITY/ZIP SAM A'AA0A)/ 945 83 PHONE ICATtE 110wrk (112,0 $k 2 -/3y/ <br />CONTRACTOR ShR."IRUM &10144A71a ;r4*. ADDRESS Z%Ab J5Ifv-41e <Sft.ed <br />CITY/ZIP V011C H/ 026C PHONE 2o9-Y6S-��1� <br />GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP_ RANGE _ SECTION <br />TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL # t4id - 19 ❑ OTHER <br />INSTALLATION: ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # <br />TYPE OF PUMP: ❑ NEW ❑ REPAIR H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br />❑ OUT -OF -SERVICE WELL 13GEOTECHNICAL # ❑ SOIL BORING DESTRUCTION: <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br />❑ WDUSTRIAL ❑ OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA <br />❑ DOMESTIC PRIVATE ❑ GRAVEL PACK/SIZE <br />❑ PUBLIC/MUNICIPAL ❑ DRIVEN <br />❑ IRRIGATION/AG <br />k MONITORING <br />WELL CASING TYPE WELL CASING DIA <br />GROUT SEAL DEPTH SPECIFICATION <br />OTHER GROUT BRAND N <br />GROUT SEAL PUMPED: ❑ YES ❑ NO <br />bfCHRISTY BOX ❑ STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑ YES ❑ NO <br />APPROXIMATE WELL DEPTH 13 S Ff, <br />PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTAR � AUGER CABLE OTHER <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WO 1LI. BE DONE IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ORDIANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br />TITLE: C FG Lb C / 5 _T DATE: *M1yg . CCO <br />Application Accepted By - <br />Grout Inspection By <br />Destruction Inspecting By <br />COMMENTS: �Z <br />PE SC <br />f <br />AMOUNT CHECK#/ <br />REMITTED CASH <br />l'wq <br />� ,•' `` <br />gaut <br />MA, <br />MD l �JJ- I•I <br />r4K_( <br />DEPARTMENT USE ONLY <br />Date Pump Inspected By <br />7767 17 <br />RECEIVED DAT PERMIT/SERVICE <br />BY <br />as ' ,t. C3P <br />Date 3 —/ 7-06 Areae <br />Dale e�1 U <br />A�Date <br />REOUEST # WELL ID# <br />L <br />