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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPT 9868 East l4azZiton Avenue-STOCKTON CA 95205-6232-(209)468-3420 <br /> 1'•I004.'EPUNUABLE PERMIT CALL(209),963--1697 FOR INSPECTIONS EXPIRES I YEAR FROM DATE ISSUED <br /> JOB'IDDRESS 1(3y(ly IS. Upkt . P-Apon pA CfT1'/ZIP f-ITCa I U61--7 �A <br /> GROSS STREET�Fr C,�c.�... �LNA�/L APN Z;v 3-U a a 03 PARCEL SIZE AND USE APPLICATION# 'J� m <br /> OWNER I IAME ^A A2 r I F, �] tI,\�Q'VL TI��• c PHONE1 -1 9 Z- ��nJ q N <br /> OWNER:'.DDRESS L.Jr7�j� �OVt1h�u�C Aw CITY/STATE/ZIP J+OC�I-n <br /> CONTRACTOR ASGI'•If Dr I�(l �tP��'��PHONE <br /> COMTRACTOR ADDRESS br.-�S CIN/STATE/ZIP1 V o _CO, !9 S ?S 7 <br /> SUBCONTRACTOR PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE21P <br /> LICENSE -)<C-57 ❑C-69 D D-09 1)Other NUMBER EXPIRATION DATE - U-/7 <br /> GEOGRAPHICAL INFORMATION: Coordinates X Y Township_ Range Section_ <br /> INTENDED Usc ;Domestic/Prival Sampling/Characterization <br /> ❑Public Water SI <br /> If diBemni from OH "�r�/y`\ U /'Apl N �j•'►v►jty(/\ me or Phone Number <br /> TYPE OF 1WORIC New Well <br /> ❑Monitoring Well - echnical ftorbodnge <br /> ❑Out-Of-Serviceo I I p ,/ o p/� i Repair <br /> Cl New Pum VxJ� 1Y Y I <br /> WELL CONSTRUCTION <br /> Drilling Method')(Mud Rotary <br /> Proposed Well Depth 2S(> lacIdGravel Size in diameter <br /> ❑Conductor Cas <br /> Well Casing Diameter_f2�_in iiess Steel O Other <br /> Grout Seal Depth /O 0 sack mixl7 gal water <br /> -)j6entonite(20% <br /> Grout Placement Metho uml me) <br /> PEDESTAL Installed By ❑ <br /> D Concrete Pedr D Christy Box ❑Stove Pipe <br /> PUMP O Submersible❑ `Standing Water Level ft <br /> I HEREBY CERTIFY-i HAT 1 1-1/3 IONS IN ACCORDANCE WITH SAN <br /> JOAOUIPI COUITP.' ORDINANCE THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH ' .1 AM IN COMPLIANCE WITH ALL <br /> IMORItERS COMPENSATION LAI <br /> iINI�N' TIONS DATE <br /> SIGNED J�^LLJ ✓ --� TITLE L,4-1,L,4-1, L tL� _3- 7 <br /> '.j a rclnA _ �1I <br /> y� rt H R 7N N UN)y <br /> P��9p0'N,76'44 — r Nr <br /> =--78 2p2,7 0 <br /> tt DEPARTMENT U E NLY <br /> Application Accepted By,1 Data Area Employee ID# <br /> Grout Inspection By Date SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection B t Date�� C.onstru ted Well Depth ft <br /> COMMENTS All 6441 41,21nj 1`1,00 <br /> PE SC Received Amount Date Permit] <br /> Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request <br /> Vie, Low 33dY3 _scc_�v 3lo u S(ZoDIUJ36 <br /> EHD 43-0G <br /> 8104108WELL/PUMP PERMIT <br />