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WELIJPUMP PERMIT <br /> SAN IOAgM COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE,THIRD FLOOR S OCKTON CA 95202 LIM 465-3420 <br /> NO�N.YEFUUNNDABLE PERMIT EXPIRES 1 YEARYROM DATE ISSUED <br /> p6 ADDRESS 3o adrJS' IN&4 . 17f Am 1,19" OTR,I -17 <br /> M GTfYaB' �O/�(�-�- sryc.J T,13 0 <br /> G � AR//C�eL S¢E <br /> > OWNER NAM`F/L/A11�__S/LL/e�- Ae�F[��� DDRESS 3o � S ' T� O <br /> CITY2 �F�"^�'POL) 1Sais' PHHOONEE c7R'�p7�� Rn <br /> ADDRFSSSp /JJ,Ify E•I�/�� C� <br /> CIfY/Le `>y ,yICI /s],/SGIpHONq�KO�la�/ C-571JCENSPJEXPDA o3 C <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y!TOWNSHIP_ RANGE_ SECTION ♦Q <br /> TYPE OF WELL: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL• 13 OTHER <br /> INSTALLATION: IVELLSYSTEMREPAIR ❑CROSS-CONNECTREPAR ❑VAPOR EXTRACTION WELLY <br /> TYPE OF PUMP: ❑ NEW *<EPAIR UP_L,12 DEPTHPUMPSET I244fT. FIRSTWATERLEVEL lB7' G <br /> ❑OUT-OTSERV ICE WELL ClGEOTECHNICAL# ❑SOIL BORB:G ❑DESTRUCTION: Com' <br /> INTENDED USE TYPE OF WELL f-ONSTR cnoN SPECIFICATION -G�1 <br /> ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA_ CONDUCTOR CASING DIA_ <br /> ❑DOMESTIC PRIVATE ❑GRAVELPACKISUM WELL CASINGTYPE WELLCASINGDIA <br /> ❑PUBHCIMUNICIPAL ❑DRIVEN GROUTSEALDEPTH SPECMCATKON <br /> ❑MRIGATIOWAG OTHER GROUT BRAND NAMR <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRI BOX ❑STOVE ME CONCRETEPEDESTALBYDRILLER: ❑YES ONO <br /> APPROXIMATE WELL DEPTH <br /> PROPOSED CONSTRUCTIONIDRI G METHOD: MUD ROTARY_AIR ROTARY_AUGER CABLE OTHER_ <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS I ALIO CERTIFY THAT MY CS7 LICENSE M CURRENT <br /> AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAMS <br /> COMPENSATIONLAWS. <br /> MINIMVM 24 HOUR ADVANCE NOTICE REQUIRE` D FOR IN1PECTIONS <br /> SIGNED THl.t�� DATE_ <br /> it <br /> If <br /> NJ <br /> ((II R�-f`�1.A u� DEPARTMENT USE ONLY EV, MC""IINTH II y ,v <br /> Apia A..pR By_j m V`�0.VSF`t�sn Dy4 b,f +a EMPLP 366 <br /> Gmu1 WSIxcEm BY DaR Pump 1#spemW y <br /> '3 yam: rare y�7� <br /> Duwcam lespemm ey fate <br /> COMMENTS: <br /> PE SC AMOUNT RECEIVED DATE PFJRMITISERVICE REQUESTM wVOICe0 WELL III <br /> CODES INFO REMITTED ASH BY <br /> 0380 65 0 SD O° 0 3 512 uJfa l�s� <br />