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n pRRp dva a n t torr b�5 t, f ,tr`�: n <br />rNi-N7 r,ry� v .. <br />WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY. ENVIRONMENTAL HEALTH DEPARTMENT 1666 EAST HAzeLTON AVENUE - STOCKTON CA 95206 - (209) 468-9420 <br />NON41MNDABLE'PERMIT CALL 209 9534697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br />CrrYl7JP <br />JOB ADDRESS <br />CROSS STREET A^1 PN� PARCELSIa r4' LAND USE APPLICATION• �xry <br />_ O A� �! V O r//1►I a -PHONEjr <br />OWNER NAME ,BION, GA gSzo ,- <br />CmISTATEIMP - <br />OWNER ADDRESS �l g. r7 �%_ Ia j <br />AnwrD.tltc Ilo-tlll�lA 1\IPi. PHONE �N 1 <br />ru CITYISTATEMP IVI 1/L �l I U/ <br />CONTRACTOR ADDRESS <br />PHONE <br />SUBCONTRACTOR <br />CITYlSTATEILP <br />SUBCONTRACTOR ADDRESS 04. 30:;V� <br />LICENSE C-57 ❑ C-61 D D-09 ❑ Other <br />NUMBlR EXPIRATION DATE(�� J(V� <br />DOMESTIC WELL SAMPLINa: General Mine*Collforrn Bacteria (4391),ii Dibrornochloropropane (4392) D Arsenic (4393) <br />1N7ENOEl1 UaeIII III YDamestlrJii P11 livate ❑ Inlgatlon/Agricullural ❑ Industrial ❑ Water Quality Monitoring ❑ Son Sampling/Characterization <br />❑ Public Water System Wler system Name co x1 N° or Ph-# Numbu <br />Ir JHI from Owner <br />TYPE OF WORK Vew Well Replacement Well ❑ Well ARarattorJModlficatlon sat❑onother a of borings <br />O Monitoring Well(a) <br />* of wells ❑ SOU BDring(s)ngs [IGeolechnlcal <br />Cl Ouppf-Servlee`Wall ❑ Out -Of -Service Well Renewal ❑ Croea�Connecllon Repair <br />❑ New PumD 0 PUMP Replacement ❑Pum Repair <br />D Ralsa well Casin <br />7M*th.,�d <br />Mud Rotary ❑ Alr Rclary ❑ Auger ❑ Cable Tool ❑ Push Pofnl ❑ Other <br />nn eplh�lL�ft. Excovatlon , in diameter ❑Open Boflom ❑ Grevel PecWGrevel Slze�_ in dlemeler <br />Con r Casing In diameter / Condu or Casing Deplhfl❑ SteelPlastic ❑ Stainless Steel ❑ Olheriameter . In ThlckneseGauge/ASTM Schad � D� nt sock mlxl7 gel water <br />Grout Seal Depth It D Neal Cement (941b bag/r10 gel water) <br />'�Qen(onhe'(26$ solids) ❑ Other <br />❑ Retardant /Accelerator (name) <br />Grout Place ant MI Pumped ❑ Free Fall ❑ Other <br />-_• Inatall�d By 0 Driller ❑ Pump Contractor ❑ Other k In ❑ Chrlsty Box ❑ Stove Plpa <br />❑ Concrete Podestal <br />PUMP ❑ Submersible❑ Turb <br />I HEREBY CERTIFY THAT I HAVE <br />JOAQUIN COUNTY ORDINANCES; 1 <br />CURRENT AND ACTIVE WITH THE <br />WORKERS COMPENSATION LAWS. <br />MINIMUM 48 HOUR <br />SIGNED <br />terlslons: Width ft Length ft ThIC <br />❑ Other HP Pump Set ft Standing Water Level It <br />ARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />FORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br />ICE NOTICE REQUIRED FOR.INSPECTIONS - PLEASE. CALL (209953-7697 <br />TITLE�Yll�llrlONN�1F' DATE <br />�`2}� DEPARTMENT E N]LY <br />Date 371 O / Area Employee IOk <br />Date ❑ PECIAL Well Permit <br />Date ❑ WAIVER Received <br />Dat Cc�}°h,IUD_ Well pth n <br />0 Y412 P r r1ti W dt t' 1 <br />D <br />Amount Data P.ermltl Irtirolce R Well IDG <br />'Re'mitted n Service RevuesFr 40 FRE11, <br />■�®Ift�®iA���� <br />goN�EcoUNTY <br />DEp'4 RTMENT <br />I � <br />WELL IPUMP PERMIT <br />