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TYPE OF PUMP: ANEW LlREPAIR H.Y. I Ut:rtn rumrocl r. ... . ........ .... <br /> ❑OUT-OF-SERVICE WE.'^ ❑GEOTECHNICAL# ❑S(":ORING ❑DESTRUCTION:_ <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION <br /> ... ❑INDUSTRIAL ❑OPEN BOTTOM WELL EXCAVATION DIA CONDUCTOR <br /> '}DOMESTIC PRIVATE ❑GRAVEL PACK/SIZE WELL CASING TYPE WELL CASIN <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROUTSEALDEPTH SPECIRCAT <br /> ❑IRRIGATION/AG OTHER GROUT BRAND NAME <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES <br /> APPROXIMATE WELL DEPTH ��-2— <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTH <br /> -I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORD <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY C-57 LIC) <br /> AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH <br /> COMPENSATION LAWS. <br /> M�NIMUI l HOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> --;7 <br /> ... TITLE YVm -Teu DATE_ <br /> i <br /> SA <br /> //��� DEPARTMENT USE ONLY <br /> Application Accepted By 1��/1 V iA i Date Y fyeaEP <br /> Grout Inspection By Date Pump Inspected By <br /> Destruction Inspection By Date <br /> COMMENTS: 5A!dTflf�',' SjSq t r. -07— CGA/awn ifibZLL ro si�i►'lG- iSJ L5 <br /> PE SC AMOUNT / RECEIVED DATE PERMIT/SERVICE REQUEST# INVOICE# <br /> CODES INFO REMITTED BY <br /> 60301`65 <br />