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Wv's t MP PERMIT 71- <br /> 304F_WFBERAVf_'I. <br /> JOA UIN COUNTY PUS A aERVICES ENVIRONMENTAL HEALTH DIVI SAN Q 95202 (209)4585420 <br /> .�Ft,pOR STpCKTUN CA <br /> NON REFUNDABLE PEFR�MIT•EXPIRES I YEAR FROM DATE ISSUED .R1 <br /> 306 ADORESR"L3S !; SC L'F S�.n P_paA APN2-41-070 0 <br /> crrYrclP fZ+y ett r n,yI/k S3 b� /{_ <br /> PARCELS <br /> OWNER NAM J�til rS f CI NI'O[C ADDRESS 7 Z 1'I� S t'fC1110I J'F U�!1� __ __ <br /> CrTY2TP L~SC•cil0y% 99'j-_>_0 <br /> PHONE �Zoq�S 3 8--7Sb� <br /> CONTRACTORrI� D,I (\q ADDRESS 5� W ROCIA <br /> xP <br /> 6cTrrzP $�Oc7cESMy�� ) 33 u " SDATE 106 <br /> GEOGRAPHICAL INFORMATION COORDINATES X Y TOWNSHIP sc RANGE- L. SECTION. <br /> TYPE ONSF WELL O NEW WELL Q REPLACEMENT WELL b MONITORING WELL k OTHER [(/' <br /> INSTALLATION 0 WELL SYSTEM REPAIR O CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL N <br /> TYPE OF PUMP, Q NEW O REPAIR H P DEPTH PUMP SET Fr FIRST WATER LEVEL <br /> 0 OUT-OF-SERVICE WELL ❑GEOTECHNICALx Q SOI.BORING DESTRUCTION W Z <br /> INTENDED= TYPE,OFULL CONSTRJCFION SPRCfFLAr UQN <br /> ❑INDUSTRIAL o OPEN BOTTOM WELtL EXCAVATION DTA CONDUCTOR CASING DIA <br /> ©DOM EMC PRIVATE 0GRAVELPACKtSIZE WELL CASING TYPE WELLCASLNGDIA <br /> ❑PUBUCJMUNICIPAL ❑DRIVEN GROUT SEAL DEFM SPFCa1CATION <br /> b IRRIGA•ITONlAC OTHER GROUT GRANA NAME � <br /> IJ MONITORING GROLIT SEAL PUMPED 0 YES 13 NO75 7 <br /> ❑CHRISTY BOX ❑STOVE PIPE / I CONCRLTE PEDESTAL BY DRILLER ❑YES ❑NO <br /> APPROXIMATE WELLDEVM fJ� <br /> PROPOSEDCONSTRUCTION/DRILLING METHOD M ROTARY AIR ROTARY AUGER LADLE OTHER <br /> 1 HEREBY CERTIFY THAT i IIAVU PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH COUSAN <br /> TN NTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS I ALSO CERTIFY THAT MY C 57 LICENSE IS CURRENT <br /> JOAQU <br /> AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLLINCE WITI3 ALL WORKMAN S <br /> COMPENSATION LAWS <br /> 1 IN1 44"OUR ADVANCE NO rlCF RI-Q111R1 D rOR(NSPT•CTInNS <br /> NED_ ��`. �r. TITL' VSc rc� .S+' �T_DAlE 1�l_—Zar�O 1FI <br /> , <br /> af. i i _ —--- -- ' <br /> i u,m <br /> —rleak, <br /> i 0 <br /> RANCII <br /> MARK <br /> Res S rs <br /> � <br /> 1 t *s <br /> I 5 <br /> nnrr a <br /> GQ <br /> JAN 8 �E <br /> _ I1M1 SAN CAO <br /> �flJ' PU64ILH(AU"SLn <br /> scs FIGURE 2 <br /> X35 SBCOR <br /> rj r..�a.yo.oe.e <br /> SITE rvui <br /> 6 oxv A$51G5 DEPARTMENT USE ONLY <br /> w <br /> Appl, uon Acceplcd Dy Da,e 4 _LQO Arc <br /> Grout Inspecum By Dale Pump Inspecled By <br /> ate- <br /> strucuon Inspccu y Date <br /> MMENTS 4 rf <br /> ty4, <br /> u J ♦�+ <br /> PE SC AMOUNT EC RECEIVED DATE P <br /> CODES INFO REMrrrEI) CASH BY ERMR'l5ERVICEREQUESTM INVOICE It WELL ID* <br /> `73 100 W/O y 99I <br /> COMPLIL02MO ! <br /> FILE COPY <br />