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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH D1V �.L4 �{ <br /> Mg E_WEBER AVE,THIRD FLOM STOC MN CA 95202 (209)468-3420 V <br /> NON-REFUNDABLE.PERMIT IC E�XIPMES I YEAR FROM DATE MUED <br /> JOB ADDRESS ! �&G� ]�. VMwjo �- r.Rd APN 61 1 - ISO—12- <br /> CffY ++ d <br /> fztp . L� _l 1 .PARCEL <br /> C <br /> OWNER NAME JC TNF-+_-7 f D M} z [(��I (I ADDRESS po 5 7-4� <br /> Crryaw �#'. AFlrr,rz_ ?*;�7'`l pHo <br /> CONTRACFOII_5t"ffr'L,. l EYAIcrlt nr! -rn _„-r. ADDRESS , 13(e -r JA if waw, Jr. ---- <br /> i <br /> CIrYlLw Shoc-ECh+n. 9'72->7S PHONE '64 S_ —'/ C-57 LICENSEN/ 21 8BXP DA y�e tl <br /> GEOGRAPHICAL INFORMATIONi COORDINATES X_ Y.— <br /> TOWNSMP�ARANGE SE SECTION 39- <br /> TYPE OF WELL: 0 NEW WELL Cl REPLACEMENT WELL, pr MONrmRm WELLN7 _.___0 CMIER <br />{` INSTALLATION: O WELLSYSTEM REPAIR O CROSS4)ONNEC'REPAIR 0 VAPOR EXTRACTION WELL F <br /> I TYPE OF PUMP: Q NEW O REPAIR H.P._ . DEPTH PUMP SSC Fr. FIRST WATER LEVEL <br /> ❑OUT-Or-SERVICE WELL O GBOTECHNIC4L#F O SOB.BORING O DFi51RUC170N: <br /> INTFKDED USE 1=OF WF.I]- COlY37AR1£TIO� CIFICATION <br /> O WDUSIRIAL .O OPEN BOTTOM WELL EXCAVAT10K DI/L__ CONDUCTOR CASING DIA <br /> 0DOMESTIC PIRLVATE 0GRAVEL PACWS¢E WELL cASINOTYPii 2K wELLCASWODIA .� <br /> ❑PUBL.ICIMUNICIPAL 0DRIVEN GROUT SEAL DEPTH !I� SPECIFICATIONS beaf6 ' <br /> .x! <br /> O RRRIGAT[ON/AO OTHER GROUT BRAND NAME <br /> ffi MON MRING GROUT SEAT.PUMPED: O YES O NO <br /> O CHRISTY BOX ❑STOVE Pip£ } f CONCRETE PEDESTAL BY DRMLER: O YES O NO <br /> APPROXIMATB WEILDEPIm__/�'�Lm/� kgSs <br /> PROPOSED CONS7RUCTIONIDRILLING ML:T'HOD: MUD ROTARY—AIA ROTARY AUGER CABLE OTHER <br /> I MMFOV CKWnWy TEAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WrM SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. L ALSO CEKnFY THAT MY C-37 LICEN=IS CURRFWr <br /> AND ACTIVE W LTH THE CALIFORNIA CONTRAcToRB STATE LICENSE BOARD AND SHAT I AM IN COMPLIANCE WITH ALL WORKMAN'S-- <br /> COMPENSATION LAWS. <br /> M I 1 UM 24 HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED &.Zil T1TIE ATES� <br /> I F. NJ <br /> ... _ �. <br /> uU 14TV <br /> r___LLEpARTI11BJVT wK oL+n.Y <br /> Application Accepted By L 4- 14% 1>1 <br /> a Lir <br /> Genal Lrtq=don B � _ - =• pomp Inspected By Date <br /> l]A Dion Inspection By <br /> +i COMM"', [ S <br /> PH - _ AMOUNT ! RECEIVED DATE PERMMMERVIC£REQUFSTM VO1C' .N WELL EW <br /> DUDES NmREMITTBD F{ BY <br /> R <br />