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�TI i�N .l� � t{{{���a�*��•.. �4F, rrf�y ��a...ii, wl i,•i`- :.. 4" .� i'I�pK�#�i ._tn' a�% y.:._ .7-"?'•;I <br /> . t 'Y:,F•�:P' _ ^i . <br /> L P� MIT <br /> SAN JOAQUIN COUNTYiE1tVIRONMENTAL HEALTH DEPARTMENT 1060 EAST HAMLTON AVENUE-STOCKTON CA 96206-(209)468-3420 <br /> ✓`/ NON-41EFUNOA40-Pi IMIT CALL 208 803 01 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB Moms , 'ry C"mP45Z-3 ig I <br /> CROSS STREEil 71W 6. AAA - t PARCEL SIM ,L.AIID Use APPLICATION N <br /> r -4 ,, . 40q Qq.Gi0 <br /> OWNER NAME - PHONE <br /> OWNER ADOIiEae CITYfSTATEMP. jj�s6 AVIr <br /> CONTRACTOR4.... y,1 .i DO ,+ 1 1. 'PHONE .../\�+'1/Yf(� '�/j — <br /> CONTRACTOR AODREaa 'r 11 .1 ] Cr YISTATE/LP MO, / CA q y(3�f7 <br /> JUEC0*MCTOR PHONE <br /> SUBCONTRACTORAODRE" CrrYISTAIT" <br /> 1 41. <br /> LIOENBE ` C-67 0 C-61 O"g .❑Other., NUMlER E.PIRATIONDATE <br /> DoMEanc WELL SAkP.LINo D General MlneraVCggtotelBact9ria.(4391)O Dlbromochloroprowite(4392)D Arsenic(4393) v <br /> INTENDED USE D powomdo Mor*rihy 0 Soil.SAmplinglCharacterization <br /> ❑Pt14fIisVilith�ftam- <br /> If elfM�n!kbnft)W7ier: Wr;,br By�I.m: sms Conbd Nome or m—Number <br /> TYPE OrWoRK ewWell ❑Replscemerltnl(VdIL 0 Wall MonsuawodMeaflon D 001ee p <br /> ❑.IGlofihorlrtll Weh(e) a oLW811r:`,O:Sotl Boring(*) r w eorkq:' O Oeotechnical s or borings 47 <br /> ❑but(7t6YV1N13h 0 oUt OfSs'rViee'Wall Renewal D Crolei�ionneedbri'Repatr , <br /> tl trawl 3.O Pum'Re'lacetrient .D Pum Repair 0 We$Iba,LnA �1 <br /> WELL CoNsThit <br /> Drilling,tlfatllbit IQld Rb O Air Rotary 0 Aug'r 0 Cable Tool D Push Point 0 O� <br /> Proposed W�11 R Exceva on .in dlerrlfler 0 Open Bottom t3rtIi3E1ickkKrovel.5iza - In diametbr <br /> D CafW Caa(ng Ilf�li m,i`m.l Cohd' of CeeI g.Dep R <br /> Well Cauiria Diarnatet In ThlrkhpriUQrAtlgi)A8TM <br /> 'Schad teel ❑Plastic O Stainless 3t sl ❑Other <br /> Grout Safi Depth D NteaCement(2.1 lb baw5.16 gal wafer) 0 Send Cefnent.— _sack mbrf/gal wulor <br /> ❑Benton ' GylLSolids) 0 Other <br /> Orgut Plipmant Meth::. PtI 6d ❑Fife Fail ❑Otliar 0 Retardant I Accelerator(name) <br /> PEdESTA,,t IfletaUid By D`DdW f 4Plk�Ccnlrtibtor ❑ Other I <br /> O CorientaPadestatl7 -� r11Vloth. R Leriglh itThiclf. _' fn. 0.Christy Box, O Stove Pipe <br /> D SuSmeteiWe0;7y}Wni F ;'HP Pump Sat R Stifls(Ing N/etgh LgveL_ <br /> I',HEREBY CEFZT1F�f T I HAYS i S IS" �'LICIkT1ON AND:THAT THE WORK WILL SE PONE 1N ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY Otto QL8,n T Til�llAltf 71Nj9 RUL ES'ANb.REGULATIONS. 1 ALSO CERT1t=Y,TLIAT MY-,Fit OCIIRED LICENSE'IS . <br /> CURRENT ANQ ACTIVE N FIE CALIFQk1d1A CbNTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WRH ALL <br /> WORKERS COMPENSATION LXYVS. <br /> MINIM ��/pJ^DDVVANCE NOTICE IRED FOR INSPECTIONS-PLEASE CALL(209)9533.70697 <br /> SIONED r. ',.x `1 C TrTLE wtv DATE <br /> .� FC MENT <br /> 40T. <br /> Ro "�Nc <br /> rHoF,�gR M��T� <br /> FNr <br /> � 3 <br /> 77 <br /> 4 <br /> DEPARTMENT -U.3.E ONLY <br /> Applkelion Accepted bj De , Cf - A.. Cf Employee IDs e� <br /> Grout Inspection ByDate ❑ 'SPECIAL Well Permit -; <br /> Pump Ina`pectlori by Dale ❑ WAVER ReCelved <br /> SMiSoft. Inspection By Date Constricted Well Depth R d <br /> Commikl S <br /> PE' SC Received Cho6k9l AmdLnt Petmltl';`:' 3 <br /> M WoILID1 <br /> Codas: Irifo' istt Reln(tted p Service Re Ytes Involee <br /> t 30` 0. <br /> EHO 4S-(M 6Atfltr WELL/PUMP PEPMR <br /> 12 <br />