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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY Efm al'alENTAL HEALTH DEPARMMT <br /> 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-(20 34 <br /> 9)46820 <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS <br /> JOb ADDRFSa <br /> ZS� (J LI.}I Gl a1 L Gt (A SPIRES 9 YEAR FROM DATE ISSUED <br /> �(?� t� cmmP LV � <br /> CROSS STREET!-:lA.S11\k+ 5 �Li ��l'(V�APN (Lt-3(o-53C A <br /> PARCELS2E USE APPLICATIOU9.. <br /> I P.0 t1Cir _ <br /> oyrNER NAME a , (Gt'r1�t v1G;�-t;e� ?-(..ci <br /> PHONE <br /> OWNER ADORESs l'L55 t c;�--:1tGl-il C- l;;o� (,�iC r C.,��. q52-470CITY/STATV21P <br /> CONTRACTOR <br /> h PHtwE I <br /> CONTRACTOR ADDRE9a` I�r•� A 1 r... - _/� -���. CRYISTATEILP_ <br /> SUBCONTRACTOR C.LI`,f�M 1G� C-L-O_SUBCONTRACTOR ADDREas (Q (r VJCC -,--"J <br /> PHONE ty1 r^� <br /> LICENSE 1`-57 C-61 -,D-09 NU8ER Z-,tfEXIRAON <br /> DA'rs 34�)'uLGr <br /> DOf.IEsTic WELL SAMUNG:-'General Mineral/COJifem Bacteria(4391):--DibromDchlaroproPane{4392):.Arsenic(4393) <br /> lNr=fineoUsE <br /> Domestic/private �Irrigaf0rLfA9dcuRural ;:Industrial Water Qu h4onitorin <br /> Public Water System ° 9 X5ai1 SampGrglCharacfof¢a6on <br /> irdCercnirmm Owner. Vlxcr GyCam Nsne <br /> COlbc(Naap or Pnana NtraSPr <br /> TYPE Oi WORK :_New Well :'Replacement Well ;:Well Aiteraiton/ModlGcation <br /> ::Other <br /> Monitoring Well(s) Sofvre9s ::SOJ Bodng(s) Porno�o <br /> �rGeotechnipl uctborira, <br /> Out-0Ofca Well Out-O•Sere ce Well Rena w11 Gro Gonne <br /> Cthn,New Pum lacement Pump Repair <br /> Repair <br /> FSeal <br /> uCTiON Ral.^e Well Casing <br /> od Mud Rotary Air Rotary ,U ger Cable Tool :;Push Point :� Other <br /> ll De th J in diameter P ft Excavation Open Bodom ,:Gravel POWGrevel Sim <br /> COnductOr C2stng in dameter / Conductor COSing Depth in d•2'n:!Ei <br /> g Diameter_in Thiamoss/GaugelASTM Schad n <br /> a! Oopth1"•� It Steel _Plaske -Stainless Steel ;:Other <br /> � Cement(241b bag/5•TO ga111-teq Sand Cement <br /> ::Bentonite(20%cEds) �Other aacmjV7atwafeent Method ::Pumped ;Free Fall -1 Other YP.SIa1L <br /> ::Retardant/Accelerator(name) <br /> P D+tn �/i� trrtalled py "DfiQer :l Pump Contractor -: Other <br /> Concrete Pedestal;Olmensicns:btild8t_R Lengh ft Thick <br /> in C Christy Bax �-:Stove P7 0 <br /> Pua1P C✓ ('Y �Submersfble�Turbine ' Other Hp <br /> Pllmp Set n er n R <br /> I HEREBY CERTIFY THAT I HAVE PREPARED T1i1S APPUCATtON AND THAT TIIr:WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUM COUNTY ORDINAN STATE LAWS.ANp RUIFS AND REGULATIONS. )ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE 4V1 E CALIFORNIA CONTRACTORS STATE LICENSE 60ARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> YdORPCEfiS COh1PEP TK) dS <br /> MtNtM VA CE NOTICE REQUIRED FOR iNS,�P1ECTIONS-PLEASE CALL(209)953-7697 <br /> °`.�. SIGNER TITLE l2G�� 7�. l.� (!q <br /> DATE <br /> Off, <br /> tip <br /> PA TPAENT U E 0 L <br /> Area <br /> APp5miion Accepted By Date <br /> Grout Inspection By Employee IDrF_�-'''T"' <br /> Date .. PECIAL Wet!Permit <br /> Pump IDSpeClion By Data _ VVAtVER Receivoc! <br /> Sob Boring Inspacfion By Date Constructed Well Depth <br /> COMMENTS R <br /> PE SC Received Checkv Amount <br /> on Info Cash DataPerrrliU <br /> Remittal Service Re ueoi 9 in1'0iC0 rd Wall la3 <br /> V iSw <br /> Ew743-0 seine <br /> vtE11 UPPM,rr <br />