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ry{T". <br />:ZSa, <br />WI)ELUPlIM7IPl`PERMIT <br />SAN JoAcuiN COUNTY ENWONMENtAL HEALTH DEPARTMENT 1888 EAST HAzELTON AVOi0e - STomoN CA 98208- (209) 488-)420 <br />NONREFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES ') YEAR FROM DATE ISSUED <br />V rP (iTYTLP df �di 7 CS <br />JoeAooREse <br />CROesSTREYT ".l �i APFI - Q' -NO PARCELS¢E9.WO LANDUaE/A�PAM.�IC/11T1gm#. <br />OWNER NAME •r 1�..k... Q - PHONE <br />m <br />OWNER AriDludS , .� <br />. _ ' " , CITr/STATEMP eycd"ni . gaw <br />CONTRACTOR n r i s.2t• �. . PHONE <br />CONTRACTOR ADDREsi< Ti: CITYISTATE/L� <br />Pics;ri 4S3S7. <br />..� <br />SUBCONTRACTOR ., PHONE <br />SUBCONTRAC't'ORAUDkEss CRY/`STATFJZIP r, <br />LICENSE C-57 D.C-81 ❑ 6-09 D Other. NU-.kk Z—-ExpiRATIONDATE T'^3�' <br />DOMEST16 WELLSA'IIsPLINO dehei'ai Mlnel'aVColNortn Baderla�(4391) j(Dibromochlompropane (4392) D Arsenic (4393) <br />Irrrt=NDEo 1— XrDamewd Vi l6 /Aprfbulturel ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br />❑ PubAc _ <br />I(dHki�ril .0{wiYt- - .WsierSystam Name Contad Name or Phone Number <br />°! Naw :W XReplacement Weil ❑ Well AlteratioNModiBcatlon D Other <br />O Monitoring Wall(*)` *of wells ❑ Soll tinow - s°rgatYtps D Geotechnical eor bodnpe <br />D OuFOfServke Well D Out -Of -Service Well Renewal D.CrOss-Connection Repair <br />• D New Pum - 0Pump Replacement Q­PuMp Repair- <br />-- _ -- - -- _ WEJ.Y-Z'GNRTRIICTION <br />OA18hg �Ie�Itod Mud Rotary p Air Rotary D Auger ❑ Cable Tool O Push Point ❑ Other <br />Propo.ed wen. Depth it In diameter ❑Open BoHom <br />(.L Excavation <br />0 Conductor Casing In diameter / Conductor Casing Depth vel Pack/Gravel Size_ in disinter <br />Well Casing Dkmeler,� In. Thickness/Gauge/ASTM Schad ZMO ft <br />Grout Seal Depth_ � ^ ft 0 Steel X Plastic 0 Stainless Steel D Other <br />{nr D _ 6 Neal Cemeot (94 lb beg�To gal water) 0 Sand Cement <br />�Benlonke (2016 ao0ds) D Other -----seek mhd7 gal water <br />Grout Place—MGM thod X Pumped 0 Free Fall D Ciller <br />D Retardant / Accelerator (name) <br />P€oEiT�l, Inshlleil6y. ❑:Drllkr D mire- ontratdor D Other <br />;0 Concrete pedeatal.ODlmeilnlone: Width R _Length it Thick <br />In 0 Christy Bos O Stove Pipa. <br />PUMP D SUbmeraibleD Turbine ❑ Other uo <br />I HEREBY CERTIFY THA rum set ft Standing Water Level III <br />JOAQUIN COUNTY ORDI (� �VEi PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH 8AN <br />NCEB, TATE LAWS, AND.:RULE8 AND REGULATIONS. WO .CERTIFY THAT MY REQUIRED UCENSt IS <br />CURRENT AND ACTIVE WMt THE CALIFORNW CONTRACTORS tiTj1TE LICENSE BOAND'THAT I AM IN COMPLIANCE WITH ALL <br />WORKERS COMPENSATION LAWS, <br />M 48 HOUR ADVANCE. NOTICE RIrQUIRED FOR INSPECTIONS.- PLEASE CALL (209) 953-7697 <br />SIGNED 66 <br />TtTL■Q.L.... — DATE <br />�r <br />®tet®®I■®■®■ii!!®®®®iii®ii®Ir"is���®�%i��i1'f!,�i��M�j0i��•�' <br />"ioiiilillllllliiliiii■iiiilN�ttiii■®ilii■ <br />I¢®!�i►lilitllii7A�IR1R��.+\iilliiiliililiiiiilii <br />`I!®iJ®JLCl'[�lil\�a �i►'!!I� <br />ililiiiii■®iii® <br />Jiillil\iilr•iiiiENO <br />®IlPltlt! �il�®li�� I®I�1mAll <br />illiiilieii■ <br />llllllli®lllllliillllilllllllllilliilli <br />illillliili <br />iii ®iiiii®lliilliiiiiiiiiliiiilliliiiiiii <br />Y <br />s <br />a <br />.y <br />■ <br />y <br />e •,k <br />r <br />T. <br />Par F, <br />O', _ fx�LAI <br />®® <br />I <br />9♦OE <br />