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WELL/PUMP PERMIT 14AM TZZ4- W IA)Tla <br /> N QUIN COUNTY PUBLIC IIEAI.TH SERVICES ENVIRONMENTAL HEALTH DIVISION 2 <br /> 704 L.WLIIL'It AVIi,'I'l IIIRD IL(�It S'IYX K'1ON CA 95202 (209)4G6.3420 <br /> j NON-Itl{FUNDADLE,1'ERMI[T EXPIRES I YEAR FROM DATE ISSUED <br /> JOB ADDRESS <br /> � �L�5 r ci1�`t/'/ t'V i - APN <br /> CI'1'Y/LIP /�1/�'1qA7y -r G PARCEL SIZE- <br /> 0 WN F R <br /> IZEOWNER NAME 1-5-44L &J'' l+-,0 ADDRESS S/19c(a— <br /> CITY&IP PHONE <br /> CONTRAcrOR L"11—K-4-4 51 ADDRFfSS. <br /> CITY2IP 777L1-1 PHONE_.j�''' -( 75 -13 S� C-57LICENSE.116 7-5Z1!XPDATE , <br /> GEOGRAPHICAL INFORMATION: COORDINATES X Y_TOWNSHIP_ RANGE_SECTION <br /> 1'YI'E OF WELL: ❑ NEW WELL ❑ REI'LACEMENT WELL ❑ MONITORING WELL N ❑OTHER <br /> INSTALLATION: ❑WELL SYSTEM REPAIR ❑CROSS•CONNECT REPAIR ❑VAPOR EXTRACTION WELL. PAYIVILi\F- <br /> RECEIVEI <br /> TYPE OF PUMP: ❑ NEW ❑REPAIR 11.1'. DEPTH I'UMPSET PT. FIRST WATER LEVEL <br /> ❑OUT-OP-SERVICE WELL *130TECUNICAL11— ❑SOIL BOILING ODESTRUCTIOI}{�LIG •'� <br /> 1 <br /> INTENDED USE TYPE OF W 1':1.1, CONSTRUCTION SPECIFICATION SAN JOAOUIN COLIN I <br /> y- �\1 PUBLIC HEAITII Sl f'Y'P. <br /> ❑INDUSTRIAL E3 OPEN BMTOM t�.IIXCAVATION DIA=L_ Cbl tAMNG'DCA' <br /> ❑DOMESTIC PRIVATE ❑GRAVELI'ACK/SI7..E WELL CASING TYPE WELL CASINO DIA <br /> ❑PUBLIC/MUNICIPAL ❑DRIVEN GROLTSEALDEPTH SPECB7CAMO�N nn <br /> Put <br /> ❑ RRIGATION/AG NO CHEMI�6TCCCVWNDNAME / SMil-IJI - o- L <br /> P14f- <br /> y a cfnti r� <br /> ❑MONITORING GROUT SEAL PUMPED: ❑YES ❑NO <br /> ❑CHRISTY BOX ❑STOVE PIPE CONCRETE PEDESTAL BY DRILLER: ❑YES ❑NO <br /> / t <br /> APPROXIMATE Vd!WDEP H `T 0 <br /> PROPOSED CONSTRUCION/DRILLING METHOD: <br /> MUD/+R�OTA�RY AIR ROTARY AUGER CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PRI1�h1tLrD fHI'S A!/' Q&T@kWvb THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS.1 ALSO CERTIFY THAT MY C47 LICENSE IS CURRENT <br /> AND ACTIVE WITH THE CALIFO IA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL WORKMAN'S <br /> COMPENSATION LAWS. <br /> IU 24 1'IOUR ADVANCE NOTICE RF, UIRED F R INSPECTIONS ����© , <br /> SIGNED TITLE I �I ATE <br /> ,'• .. ri I��kr <br /> I / e td' <br /> MANTECA Wtler PNASE II NPANSION PROJECT /, <br /> i <br /> -- - - <br /> ITE <br /> / 'i• N <br /> I <br /> DEPARTMENT USE ONLY q37 y LAP it <br /> Application Accepted By Datc 2 Area Z C — <br /> Grout Inspection B Cate�Pump Inspected By —.N <br /> Destruction Inspection NO CHEMICA race <br /> COMMENTS: ? dN or— �o'�e_ICAL <br /> A l�1L <br /> phi / , <br /> If <br /> PE SC AMOUNT CHE RECEIVED DATE e PERMIT/SERVICE REQUEST. INVOICE. WELL IDN <br /> CODES INFO REMITTED CASH BY <br /> y37'1 t 21M 117-%- <br />