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P PERMIT WEIR" ;M ERVICESENVIRONMENTALHE68-42pNI510N v * SAN JDAQUi,COUNTY PUBLIC}. - EA 304 E.WEBER AVE,THIRD F��.-.�><STOCiCFON CA 95202 (209) NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUE" APN / IOB ADDRESS ( s( C,� PARCEL SIZE CTIlym OWNERNAME k h f ADDRESS PHONE �G •d' �� CONTRACTOR ADDRESS Q j i Z8I C-57 LICENSE# EXP DATE CrrYrLIP 9s3 a PHONE Z o y- X35 r j y TOWNSHIP_ RANGE SECTION rTYPEOFWELL: HICAL INFORMATION: COORDINATES X ❑O'THER ❑ NEW WELL ❑ REPLACEMENTWELLMONTTQRINGWELL#TION: ELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPORACTION WELL# TYPE OF PUMP: ❑ NEW j�REPAIR H.P. 2 DEPTH H PllMP SET - FIRST WATER LEVEL ❑OUT-OF-SERVICE WELL ❑GEOTECHNICALft- p SOIL BORING ❑DESTRUCTION: CON; RU T N P I-I TI N AFD USE TYPE OF WEWEL_L 1 ❑QJDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR CASING DIA +KOMFSTICPRIVATE ❑GRAVEL PACKlSIZE WELL CASING TYPE WELL CASING DIA ❑PUBLICIMUNICIPAL ❑DRIVEN GROUT SEAL DEPTH SPECIFICATION OTHER GROUT BRAND NAME ❑IRRIGATION/AG GROAT SEAL PUMPED: ❑YES ❑NO I ❑MONITORING - CONCRETE PEDESTAL BY DRILLER: OYES ❑ND ❑CHRISTY BOX ❑STOVEPIPE ' r � APPROXIMATE WELLDHP1 - PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TIIE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUHV COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT JA C-57 LICENSE IS CURRENT AND ACTIVE WITH OR CALIFORNIA CONTRACTORS STATE LICENSE B ARD AND THAT I AM IN COMPLIANCE WITH ALL WORICALAN'5 S. MINIXYM 24 IJOUR ADVANCE NOTICI;REQUIRED FOR INSPECTIONS TrCLEt�I✓I �eG� ,DATE SIGNED S k t i DEPARTMENT USE ONLY n Date Area ID# C/ Application Accepted 6y_ -� - i Grout Inspccuon By 10 Date Pump Inspected Hy Date - Date Destruction Inspection By I ' COMMENTS: [�v PE SC AMOUNT ECK RECEIVED DATE PER lSERVICEREQUEST# INVOICE# WELL CODES IN ED REMn-MD CASH BY r _ • 3 0 5�