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JAIV JUAQUI•V IUM III I'MI-1 III:rVL•111111 1.".. .--- <br /> 304 E.WEBER AVE,THIRD FLOOR STOCKTO' 95202 (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 Y�!1•CFROM DATE ISSUED(�J/!}^/7 <br /> JOB ADDRESS' P�fr aim JDcM I r-� yn�T 1(l_ APN - 00 <br /> CITYrZIPS l f�C.ILTV� C%0 -` PARCEL SIZE b O <br /> OWNER NAME ,-� -) ADDRESS • /-4N IZ-'�'�v 14!5 <br /> CITY2IP 6yt91� '15,2II-C.11kt7�+t �f-A-4f �'c(� r�l/�tl�_���P,H�O�N�E� 12"57. Ia42-- 9460-2— <br /> CONTRACTOR <br /> CJZ <br /> CONTRACTOR ams. �i.�C�) r���� �-� /�J SS 1 `SY"�"`u� W AUj,, Z� <br /> CI'TY/ZIP '1!OIt�l4j Ct•� Jt.� �O ID PHONE C1C&� S�' 1-70 C-57 LICENSE# �`TZ-EXPDATE/L°+ <br /> t <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y TOWNSHIP_ RANGE_SECTION <br /> ,,,, C EoT'14F4 <br /> TYPE OF WELL: ❑ NEW WELL [IREPLACEMENT WELL ❑ MONITORING WELL# l,WTHER <br /> INSTA ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# <br /> TYpE-OF-PUMP.----M NEW ❑REPAIR H.P. q� DEPTH PUNIP SET FT. FIRST WATER LEVEL <br /> ❑OUT-OF-SERVICE WELL NGEOTECHNICAL# I ❑SOIL BORING ❑DESTRUCTION: 'Cn� <br /> �- TvnF n.-.••�;; CONSTRUCTION SPECIFICATION V ` <br /> ❑INDUSTRIAL ❑OPEN BOTTOM aEllil.L EXCAVATION DIA 6_ CONDUCTOR CASING DIA <br /> ❑DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE . �WELL CASING DIA <br /> ❑PUBLICJMUNICIPAL ❑DRIVEN GROUTSEALDEPTH FAVI--- SPECIFICATION <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING G$.�D: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CON ILLER: ❑YES ❑NO ?�+ <br /> APPROXIMA` ,IN <br /> TP. L DEPTH J'P 'Zg <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TI WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY C-57 LICENSE IS CURRENT <br /> AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. _ <br /> INIA1 2d U ANCE NOTICE RI'sWIRGD FOR INSPECTIONS <br /> SIGNED - LAI- _TITLE ',4—'1 v/L 04'-41 Al4L�DATE <br /> M > <br /> :�, a y�_. ll►`'' '1 <br /> 8 8 3-ag g ' ; _ I <br /> (- If <br /> v— <br /> i <br /> DEPARTMENT USE ONLY �7 <br /> Application Accepted By (,t,'IA_wA�l4f) Date3Loy/ Area ._EMPID# <br /> Grout Inspection By _ AMC?j` Date Pump Inspected By Date__ <br /> ww Q�rxcr tiC([c f �:;2^otx7�ct�n-.,,v� P�3t'i��c f rwtat« <br /> Destruction Inspection By `(` ate <br /> COMMENTS:( n w. M.G '-' <br /> 11 A p j.�l�2 Z11i$3.S' <br /> PE SC AMOUNT CHECK#/ RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# WELL ID# <br /> CODES INFO REMITTED CASH BY <br /> y3 Z3o.o0 9Y� I b g�6 <br /> C O f\/ <br />