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,t <br /> 4-1 "LLIP-Wp PERMIT <br /> SAN JOAQUIN COMTFY PUB UC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE., STOCKTON CA 952M (209)469-3420 ' <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> PARCEL SI'LFJAPN n Cr C1TY1'LIP • ��' <br /> _GwNFx NAM �� �An➢Hass _��: 'S" �l.��7u s E - <br /> mTYfZIP G'/- - 7 -�7 PHONE ��--^- - <br /> CONTRACTOR C�"I+Iy!"c ZJJc�[ ADDRESS'Y2 �• � 7 f <br /> l / <br /> _f 5_1.7�. PHONE f 7 d`��• l�t —I�{n.� - - <br /> GEOGRAPHICAL INFORMATION:COORDINATES X_ Y_TOWNSHIP_ RANGE SECTION <br /> TYPE OP WELL: 0 NEW WELL I3 REPLACEMENT WELL 0 MONITORING WELL N��`T'T'r`� 171 DTNPR <br /> INSTALLATION: G WELL SYSTEM REPAIR Q CROSS-CONNFCT REPAIR ❑VAPDR EXTRACTION WELL# <br /> TYPE OF PUMP_ 0 NEW G REPAIR H.P. DEP'FFi PUMP SET FI', FIRST WATER LEVEL <br /> GOUT-OFtiSERVICE WELL ❑GEOT13C[FMCAL# ❑SOIL BORING ❑DESTRU=GN: <br /> INTENDED TJSE I-YA OF L CONSTRUCTION SPECIFICAIION .✓ <br /> ❑INDUSTRIAL 0 OPEN BOTTOM WELL EXCAVATION DTA CONTTACTOR CASING DIA� <br /> .0 DOMESTIC PRIVATE G GRAVEL PACIUSI"CE— WELL CASING TYPES l,-`.' AA WELL CASING DTA� <br /> ❑PUBLICMUNICIPAL 12 DRIVEN GROUT SEALDEPTH 2— SPECIFICATION <br /> - AA � Cl1.rv�o <br /> 4 SRRIGATIGNIAG OTHER GROI}T BHANp NAME <br /> MONITORING 2.4 H R M C:)T!C E GROUT SEAL PUMPED: ❑YES �NO <br /> ©CHRISTY BOX STOVE P E � ALL CONCRETE MDESTAL BY DRILLER. 0 YES 0 NO <br /> APPROXIMATE WELL.D5P7N_ T\.I-;�; �r'T'l <br /> PROPOSED COMMUCTIONIDRILLING METHOD_KUD ROTARY AIR ROTARY GER CABLE OTHER <br /> I REMY CERTIFY T{IAT 1 HALVE PREPARED THIS APPLICATION AND TITAT TILE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDIANCES,STATE LAWS,AND RULES AND REGULATIONS OF SAN JOAQUIN CDIINTY., <br /> SIGNED• <br /> TITLE: !'ar c DATE: �' /.� ��• <br /> g� r - <br /> d <br /> 91 <br /> EN RC IMETN t '.Al ri 3A. <br /> =pr mares-= : <br /> k ,_ <br /> _r <br /> ifs DEPARTMHNT IFSE ONLY [y7 <br /> Application Accepted By_ 1Lf, .4 D�kc r '� {nAm—=�— <br /> Grunt Inspcclion By DRtc pump Inspcctcd By ➢Ric <br /> Destruction Inspection By �7 — — riate <br /> COMMENI'S:,4 '.ar/'0l -- <br /> i <br /> PE SC AMQLFNC pl1 RECEIVED DATE PERMITISERVICEREQUFSTIY> WELL IDN <br /> CODES INFO REMITTED 1�kCAwS BY <br /> {�4 k <br /> 'h 5l� <br /> �k <br />