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PVDWAL IrtaLibd By Drifter Pump Contractor Other <br />Concrete Pedestal Dimarislorrs: Wath ft Length R Thldt in 1 Christy Box Stove PiPa <br />PUUP Vtmersible Turbine O*w HP Pump Set ft Standing Water Levet ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DOME IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ES, STATE LAWS, AND RULES AND REGULATIONS_ 1 ALSO CERTIFY THAT MY REOUMD LICENSE IS <br />CURRENT AND E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPI LANCE WITH ALL <br />WORKERS COMP <br />ADVANCE NOTICE REQUIRED FO INSPIE�C^/TI�OQNS{�-- PLEASE CALL (209) 9�3- <br />TITLE �Y G VL r r t oyi DATE (0 <br />�W o <br />�LU i N <br />W N <br />W <br />EP <br />Application Accepted By <br />Grout lnspeocri By <br />Pump Inspecum By <br />Soil Boring Inspection By <br />COMMENTS <br />T Dale S�Y <br />� Date <br />Date <br />Date <br />Date <br />201""�P <br />9 20 <br />',�� HEALTH <br />Aa Employee tott225WWW <br />SPECIAL Well Permit <br />WAIVER Received <br />Corubucted Wad Depth ft <br />WELUPUMP PERMIT <br />==01- W4 <br />SAN JoAouiN CouNTY ENVIROWIENTAL HEALTH DEPARTMENT 1868 EAST HAZrLTON AVBNE-SToacroN CA 95205 - (289) 4683120 <br />NON-REFUNDABLE PERMIT CALL 09 7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />�a 6rlt,6 E SCG G 53 <br />.• ) <br />CROs STREET % ( OAPN +�� PARCEL StM LAID Use APouCATm tt <br />m <br />:OWNER NAME M 0, VQ <br />90 <br />_-/(/PMONC <br />OWNER ADDRESS V CITY A � <br />(� <br />� V <br />n zo <br />CONTRACTOR <br />qq-77!76 <br />CONTRACTOR ADDRQ33. <br />N <br />'.(AI <br />SUBCONTRACTOR P <br />s <br />/ <br />SUBCONTRACTOR ADOREW ` <br />�CRY�IST/AATEAL /n//�� <br />VC 00 <br />�]• <br />LICENSE C-57 -61 D-09 Other NUASM �+` ORATION DATE <br />GEOGRAPHICAL I T10N: Ceordes aratX Y Tow -hip — RWW 36COM <br />t� <br />tt' \ <br />INTENDED USE DOeS OPrivate Irrf93WIVA9ria2tXW IrAUStffal Water CUelity Mwapru q SOd SQTIping/dtaraderiz�on <br />m <br />CV <br />,C <br />Public Water System <br />1 <br />tf Clflermt rrom Owner <br />TYPE OF WORK New Well Replacement Well Well AAeration/Modification Ottw <br />Monitoring Well(s) 4 of wells Sod Bonng(s) 4 of bOr*W . Geotsdfrvcal d <br />Out-OfService Well Renewal Gos-Connection RepSeWm <br />Purrip Repair Rase well casing <br />R enl <br />W"c1.L G;rr+STituGTl4r+ <br />\j\�� <br />1, <br />Orilling Method Mud Rotary Ax Rotary Auger Cable Tod Push Poiret Older <br />_ <br />V <br />Proposed Well Depth ft Exmztion in diameter Open Bottom Greed PadJGravef Sea in diameter <br />Conductor Castrlg in diameter / ConductDr Casing Depth It <br />Wed Casing DtameW _ in ThwknessJGatlge/ASTM Schell Steel Photic Stamm Steel Other <br />Ot <br />Grout Seat DoPtit k Neat Cemied (94 lb bag --10 gal wafaj Sand Cemant sack mor!! gal Water <br />�r]t <br />Benton" (20%sdids) Ottw <br />n <br />Grout Placement Method Pumped Free Fag Other Retardant / AOcde/aEor (nanls) <br />PVDWAL IrtaLibd By Drifter Pump Contractor Other <br />Concrete Pedestal Dimarislorrs: Wath ft Length R Thldt in 1 Christy Box Stove PiPa <br />PUUP Vtmersible Turbine O*w HP Pump Set ft Standing Water Levet ft <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DOME IN ACCORDANCE WITH SAN <br />JOAQUIN COUNTY ES, STATE LAWS, AND RULES AND REGULATIONS_ 1 ALSO CERTIFY THAT MY REOUMD LICENSE IS <br />CURRENT AND E CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPI LANCE WITH ALL <br />WORKERS COMP <br />ADVANCE NOTICE REQUIRED FO INSPIE�C^/TI�OQNS{�-- PLEASE CALL (209) 9�3- <br />TITLE �Y G VL r r t oyi DATE (0 <br />�W o <br />�LU i N <br />W N <br />W <br />EP <br />Application Accepted By <br />Grout lnspeocri By <br />Pump Inspecum By <br />Soil Boring Inspection By <br />COMMENTS <br />T Dale S�Y <br />� Date <br />Date <br />Date <br />Date <br />201""�P <br />9 20 <br />',�� HEALTH <br />Aa Employee tott225WWW <br />SPECIAL Well Permit <br />WAIVER Received <br />Corubucted Wad Depth ft <br />ENO+i M WELL /PLAY Pewrr <br />4rX 12 <br />==01- W4 <br />ENO+i M WELL /PLAY Pewrr <br />4rX 12 <br />