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WELL/PUMP PERMIT <br /> SAN I..AQUIN COUNTY PUBLIC HEALTH SERVICBS ENVIRONMENTAL FH?A 'Ill DIVISION <br /> 304 E.WeHBR AVE,-MMn FLOOR STO XMN CA 93202 (209)468-3424 <br /> —1 <br /> NONREFIJNDABLE PERMIT EXPUIFS 3 YEAR FROM DATE ISSUED / <br /> JOB ADDRESS12. _!V APN .SAX JI <br /> Crr,YrLIP Lo rl PARCELSUM <br /> OWNER NAME_. N C ADDMS <br /> CrIYII..E' 1 PHOON <br /> A— G E C <br /> CONTRACIOR /Z41i.� Qt t w. ADDRESS �7 f <br /> Cr1Yr7.I -"S)0694e PHONE —C-57 UCENSEN_?—__Elal <br /> GEOGRAPHICAL INFORMATION: COORDINATES X_ Y TOWK9NIP RANGE SECTION <br /> TYPE OF WELL: NEW WELL Q REPLACEMENT WELL. 0 MONITORING WELL ❑OTHER <br /> INSTALLATION: O WEILSYSTBM REPAIR ❑CROSS-CONNECT REPAIR p VAPOR EXTRACTION WELL# <br /> TYPE OF PUMP:'94 NEW ❑REPAIR H.P. S DEPTH PUMP SEr Fr. RKST WATER LEVEL <br /> 0 OUT-017SERVICE WELL 0 GBOTECIWICAL0 O SOILBORM O DESTRUCTION: <br /> RallawilIM T.YPROF WI2r_t_ CONSMUCIMSPECfflCATION <br /> ❑INDUSTRIAL O OPEN BOTMm WELL EXCAVATION DIA CONDUCTOR CASINO/DIA <br /> PE V <br /> LMICPRIVATE AGRAVELPACKJSEM WELL CIZING7YC. WELL CASINO DK—G- <br /> 0 <br /> K G — <br /> 0PIJBLJCNLN(C[PAL 0DRIVEN GROUT SeAL.DESPM'L—a'0 SPBCEW-ATION <br /> ❑IRRRIATIOWAG OTHER GROUT BRAND NAME CE J2 6 4 <br /> L3 MONUORING GROUT SEAL PUMPED: ,XYES ❑NO <br /> 0 CHRISTY BOX ❑STOVE ME ' � CONCk-E-rE PEDESTAL BY DRDI..ER: %YES 0 NO <br /> � <br /> APPROXIMATE WELL <br /> PROPOSED CONST RUCTKW ORIlANG METHOD: MUD ROTARY K AIR ROTARY AUGER CABLE OTHIM <br /> I HEREBY CERTIFY TaAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONR IN ACCORDANCE WTTH SAH <br /> JOAQUIN COUNTY ORDINANCES,STATE,LAWS,AND RVLES AND REGUI.AMONNS. I ALSO CERTWY THAT MY C-57 LICENSE IS CURRENT <br /> AND ACTI'PE WITH TELE CALEFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> MINIMUM 24 IIOUR ADVANCE NOTICE REQUIRED FOR INSPECTIONS <br /> SIGNED >� Tnix C)--,oL-4E- DATEI - CULl I ::i <br /> 7' <br /> Y <br /> 11 V1 fill "llf1m . 4-A <br /> i <br /> I <br /> t <br /> DEPARTMENT VSE ONLY <br /> Applicahm Ac—ptcd ly �� �+ Datc ��•� `� A� I]NPD]N 16 9 <br /> Gout Iuspectioa BYDain! nV inspected By Duce <br /> Destruction Iaypec0oo By Date <br /> COMMENTS: 7-1 [ _� s Cb4/�fR�e: YN7i .. �o(JQTA,e. �LfioNC' a I-A, <br /> SS6; 40,-4k w ZOD�T�h! <br /> PB ISC AMOUNT ECKM RECEIVED DATE PERMTT/SERvICHREQUEST* INVOICE. Wu.LMr <br /> C�OjDES INFO REMrrrED BY �f <br /> o d 2 -7 <br /> S� Do 1bb . <br /> t <br />