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07/05/2002 13: 20 00=45213 FIFTH =LDCR PGGc = <br /> WELLA UMP PERMIT i <br /> SAN IO.AQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION <br /> 304 E.WEBER AVE,THIRD FLOOR STlOCKTOIV CA 95202 (209,468,342D <br /> I NON-RFFUNDABLI;PERNUT EXPIRES I YEAR FROM DATE ISSUED <br /> )OB ADDRE,Ss_ 90,E �". CrJe�a�c�l�raj APN L `13 -d <br /> � <br /> r <br /> CII'YlL(P_ Ma-y+ T�G�t 9 T 3=3 l -PARCEL SIZE_ 4 G <br /> 01�N !�' <br /> ERNAtdP ZMif/ <br /> Z2ee) 5rr0ZJIJ1/5ADDRws 7 �� �7y4g4 rJ �� <br /> CITYMP 04,m95 3 �•`6 _ PHONE l y2 "?"V <br /> CONTRACTOR v74 <br /> r ]jm <br /> �DRREESS 75' <br /> 1� aT /P yi <br /> CTTYl71P Z~J//�^1 7ro� y f PHONE -Lam,:?7 �4 zepz-; C.57 LICENSEi2YExa QATE <br /> GEOGRAPHICAL L'VFQRI4ATION: COORAIIVATES X Y TOW rSH1P-0 RANCE 7l SECTION <br /> TYPEOP WELL: a NEW WELL ❑ REPLACE3NIEN'I•WELL MONTCORAIC WELL# G ❑OTHER <br /> INSTALLATION! D WELL SYSTEM REPAIR D CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# ' <br /> TYPE OF PL.MP: Q NEW ❑REPAIR H.P._ DEPTH PUNIP SET_- FT, FIRST WATPR LEVEL <br /> D OUT-OF-SERVICE WELL ❑GFOT•ECH.ICAL,4D SOIL BORNG DESTRUCTION: 6i <br /> I�"TF.NDEI2USE TYPE OF WELL COMTRUMQN SPECEEICAMON f <br /> D IN0t;S7RLIL ❑OPEN BOTTOM WELL EXCAVATION DIA..� CONDUCTOR CASING DLa .vW <br /> DOMESTIC PRIVATE KGR.AVEL PACKISIZE WELL CASING TYPE_ �ll G WELL CASING DL+. ;� <br /> ❑PUBI.KiMUNIMAL ❑DRIVEN GROUT SEAL DFpTH O ? / SPECIFICATION <br /> ❑LRRIGATTON/AG OTHER OROUT BRAND NAME <br /> )i�LONTTORLVG GROUT SEAL PUMPED: D YES In No <br /> ❑CHRISTY BOX ❑STOVEPIPE CONCRETE PEDESTAL BY DRILLER- O Y6S ❑NO <br /> APPROXIMATE WELL DEP1}i— D r <br /> WG//S Ta b e � r�rWCI nolle <br /> IR e <br /> S iiRc rix�Ti y� <br /> PROPOSED CONUCTION/DRILLING METHOD: MUD R07ARROTARYAROTARY AUGER <br /> I HEREBY CERTIFY THAT I IIAVE PREPARED TRIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> 1 JOAQUIN COUNTY ORDINANCES,STATE LAWS,ARID R.ULZS AND REGULATIONS. I ALSO CERTIFY THAT MY Cd7 LICENSE IS CURItIrlvi ' <br /> AND ACTIVE WITH THE CALIFOI,L141A CONTRACTORS STATE I•.ICENSE BOARD A.`M THAT I ANI IN COMPLLL_NCE WITH ALL WORJOLCN'S <br /> i COY�E'�aTfp!I.AK� <br /> F AIYTIvfE USE ONLY <br /> Appllcadou AcccpmcL By_�ylpp�l tc v' E <br /> Gout inspeciicn By D_atc Inspcctcd By Date <br /> ion f potion B• <br /> �tus ns! ! <br /> I <br /> C!OVI'r1ENTS: <br /> PE SC I AMOUNT C.LMCYjw RECEIVED DATE PERMIP/SERVICE REQUEST# INVOICE 0 WILL IN <br /> CODES E:`vlfT'I'ED C H A B <br /> Z�QZ foo 3 �3 S� 7,0 <br />