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WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 186.8 EAST HAZELTON AVENUE- STOCKTON CA 85205 - (209) 4663A20 <br />NON-REFUNDABLE PERM CALL (209) 953-7697 FOR INSPECTIONS EXPIRES 'I YEAR FROM DATE ISSUED <br />JOB ADDRESS „GICKS`=/L9r9n� itcAl-) c:rYRIP -S7LiC*fT0,4 <br />Coosa STREET/f-/C//(/I AtIt/Nza APN /2%/—�%^(�PARCEL SQE LAD V>1Q AIPLKATiONA <br />OWNER NAME _., P..F.d?Q - J7(4 3 -Y000 7 I S <br />OWNER ADDREas e�(`�' x/ 7n7c--noC2 CrrYMTATVZ0 • !�/.JL F �-1 <br />CONTRaCTCR � l�C./T ��IC:7I�/C.. C.�4S P.We '64,/+1` !i <br />CONTRACTOR AODREas / Ch�fi?^ crrrBTATe?» S�i��OSc` C9 <br />3uscQHTRACTOR n► ,e l� G-� �: Iy_ PHO*IE N (�33 <br />SUBCONTRACTOR ADOREas � JV - � m�STATER» /a t LI -If 241P-7 <br />LICENSE 5-, C-61 D -N Other Noreen EA►IRATIONDATE "` L/ Q% <br />DOMESTIC WELL SAMPLING: General MineraUCottform Bacteria (4391) Oibronnochloropropane (4392) Arsenic (3393) <br />^INTENOEO USE Domaatc'Private ImgatwMAgricultural InOUstriel Water OuNdy Momtorsng <br />PUWK Water Sys:em <br />rt .Tin t_ 0-. 'Nnr sy%� N_ Cha N_ t i b.' <br />TvpE Oc WORR Now Well Replacement Well Wed AUMwtvModiRCetion-}(Omer C - <br />Monitoring ell g Weals) a of wells SBonng(s! • -cs Geotecrnr ! act brovgs <br />0ut-0f,S44v" Well Out-011-Serv+a Well Rene"l Cress -Connection Repair <br />_ New Pump Pimp Replacement Kmo Repae Raise Well CasingWELL CONSTRUCTION Q =� <br />Drilling Method Muo Rotary Aa Rotary Auger CaCie %Zc P.;sh Po r�' O'hor <br />Proposed Well Deptn R Excavation Oren SO:tom Gravel Pacic(leawel Sao m diamettit <br />Conductor Ca" in otarneter CorCUC!or--a-,r.; Leper 1 <br />Well Casing Diameter _ In TMgbwsefGEuge/ASTM SCac S,ee, Ptasuc Sta:rllKs Steel Otr`rr <br />Grout Seal Dept,—ft XNeel Cement -;Ar :C o8975- r:; gat Nater, Sand Cement --- Sack rTxz, :;a, Nater <br />Bentonite (20% sods) l Other <br />Grout Placement Method Pumped Free Fall Oti+er Raterdont i ACCOlantor (name) _ <br />Pt2L TAL Instailad By Drier Pump Contractor Other <br />Contrera Pedesr-al Dfinenaions_ Wath R Len _ R Thick ;r. Christy Box Stove Pipe <br />PUMP S Ct r t:,s tie Turwne Other HP PUMP Set R Standing Water Lev!{ R <br />1 WITH HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE SMI <br />JOAQUIN CO NTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT MY Rec"RED LICENSE 13 <br />CURRENT ACTIV WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS C LAW, MIN U UR ADVA E NOTICE REQUIRED F/t�1pp NSPECT�I.��QNNS�-PLEASE <br />/C'�AyL�L� (209 953j-7)897 <br />Slawo Tm a ��i 11 0; ► /yrs vim* / r L(r' _ _x �� <br />AR <br />e <br />Application A -opted By <br />Graz tmpecBdn By <br />Pump Inspection ey <br />Sod So(" Inspection By <br />COMMENTS <br />111057 <br />No <br />LENT U E O L �'J�t/,/��,� <br />Data 4rea Ern*yva ID#Aif — _ <br />tale SPECIAL Wall Permit <br />Date _ WAfvER Received <br />Date Constructed Wall Depth ft <br />Ewuoe aetns gEtl"AV PERMIT <br />._TIc.9�wo <br />Mr. I <br />c7M»©lowal <br />Ewuoe aetns gEtl"AV PERMIT <br />