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-Ryml,� <br /> WELUPUMP PERMIT <br /> SAN JOAQUIN COUNTY ENmoNMENTAL HEALTH DEPARTMENTIMEASTHAI2LTONAVFI.VE•STO(-xYONCA95205-(209)460-3420 <br /> NON-REFUNDABLE <br /> -{PERMIT CALL 2(19 953-7697 FOR INSPECTIONS CIEXPIRES 1 YEAR FROM DATE ISSUED <br /> JoeAQDREgy '\ 156 W_ �19 - <br /> CITY21PCRasSSTREET { `B0'. Rt _APP $I1Z+� U APPIICATIQN# <br /> ONRaR NAME a <br /> DrixER ADDRE$s >� �f���Of h CFrY, FSP O alL <br /> CONTRACTOR PHONE(20—C/� <br /> A �3 Fs--N <br /> CONTRACTORADDRES9 U Y1 Orr1JTi71QiQ'-IP (, on <br /> SUBCONTRACTOR <br /> PRONE <br /> SUBCONTRACTOR AOnREyS CR=ArE0P <br /> 110E1ISE C-57 C-61 0-09 -Other NumiiER334489 F-XPH tom DATe Z <br /> 1GEOORAPH1eALINFORMAmOet CoordinatesX Y Township_Ranges__ Sedloo <br /> htrENom a _ e56CA'rlvale Irrigation/AgtadhMal L 1110istdal _WeterQuality MWhpring L Sol Samplowcharaclertz0on <br /> Public WaterSys.tem <br /> NOfvera frtanOmrm ane or • u• <br /> TYPE OF WORB _New Well L Replacement Wen L Well Alleralian/Acdicaa X01her <br /> -MWIIoring Wee(s) #Or WERS L Sod Bodng(s) Rof°on`oe J Gwechnical ""diV <br /> Ou9-0t-Service Wed r OUt-OfSenice Well Renewal 1 Cross-Connection Repair <br /> 7Casi -New P,, r Pum R IaceTlent r'Pum _ air I Raise Well Casln <br /> rg <br /> dRotary LAIrRClary LAUger _COGTO01 L Push Point L OtherAy R EAT.avadon in fbameter LOpenl3GhOM -Gravel PaduGravel Size In cWndW �ndudaCasing inclameter / CWduciorCasingDepth R VF® <br /> ter In TNdtneS9 GaugeIASTM Shced t Steel l Plastic I Stainless Steel r Other JUN Grout Seal Depth ft INeat Cemerd 41bba sack (J n <br /> {9 g/S10 gal»ester) i Sand Cement J <br /> Bentonke(20%solids) T Other f} <br /> Grout Placement Method L Pumpod L Free Fall L Other L RetardW[jAccderator(nems) J04 ?01V <br /> EEMILIM& Installed By J Driller U Pump CWtrador Other VP Q0,v l: <br /> Concrete Pedestal IOimenslons:Width_ft I.englh 0 Thick in I Christy BOX I Stovepipe <br /> CTH p�p FIyT�N�Y <br /> P - uiXTlelsible Turbine 101har HP Pump Set ft Standing Water Level ft �RrMEN <br /> 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN T <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> .4 0p LWORKERS PENWS. <br /> 4 v POLYP : — INI UM UR DVANCE NQTICE REQUIRED F I SPETI N6-PLEASE CALL(209)953- 97 <br /> BrGN TiTLE � /7 �� <br /> DATE <br /> I I I I <br /> 61 Al I <br /> I <br /> I <br /> - I I <br /> I I <br /> I I <br /> t <br /> EP TMENT U E O LY <br /> ApelGroi t Insp e tedlion By Cate- � <br /> Prem Employee IDD � <br /> Grout Inspect on By Ode O SPECIAL Well Permit <br /> Pump lnspe ctlon By Date n WAIVER Received <br /> COMMENTS Sal Boring Insp�W By /Date Constructad Well Depth _H <br /> PE Receive urrtPermit! -__--._---_----__-- <br /> Codes Info B Cash Remitted Omte Service uDst Invoice# WellID# <br /> tdio "I <br /> 4f m S� <br /> 7(-Z) waLmuaPVErtMrt <br />