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WELL/FlUMP PERMIT <br /> OMNI AN,i0AOU1N COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 'SGE EAST HAZELTON AVENUE-STOCKTON CA 95205•f209)46&341,NON-REFUNDA Mr CALL 209 �9f533-%59?=C INSPECTIONS T�/E/XPI E I YEAR OM TE ISSUED 7 U <br /> e A00RESs V CmZ <br /> CROSS STREET O APN 11 — T" A PARCEL SIZE J-IJ6,�LANO USP <br /> 'ON <br /> OWNER NAME l/,� J p R s <br /> PH <br /> OWNER ADORES r ClTIA <br /> TtICA <br /> ,CNTRACTOR �/J� / '�^' ✓�' Pn NE IqO/� CI� <br /> `r �I CITY/STATErL! V <br /> CONTRACTOR AD 1) <br /> S:,000NTRACTOR NN _ HONE <br /> SUBCONTRACTOR ADDRESS Cl AT�p <br /> CENSE �7 • C-6i D-09 Other 7,1 NuMa��� EJONRATtoNDA O <br /> .DOMESTIC WELL�Gtpi;Nc: General Mineral/Coliform Bacteria��39?; Oibromochloropropane(4392) Arsenic(4393) <br /> IN ENOED Us • OomestiaPnvate ImgatioNAgncult.Iral Ineustne' 'Nater Ouahty Monitoring Soil Sampling/Characterization <br /> Pupl:c Water System <br /> i1 CM6renl frpr Jwr'.er. 'Nater System V:,-e Contact Name or P"one NumW <br /> TYPE OF WORK New Weil Reolacemert Well Well A!'crahon:MocifcaCon Other <br /> Moritorng:Vellls; x of wells Son SCrr:5 ° 00n"B� Geotechnical o bcr.r s fi <br /> Jus-Of-ServiceOut-07-SEr,. %.eu Renewal Cross-Connection Repair <br /> New?umPun Replacement <br /> p pump Pic:;- Raise Well Casine <br /> WEL-CONS,TiUCTION <br /> Galling Method Mut Rotary Air Rotary Auger Caote-o.• �_Sn Point Other <br /> Proposed Well Depth h Excavation n c;a--ater Open Bottom Gravel Pack/Gravel Size ;n diameterl I �/ <br /> Conductor Casing in diameter , Corrcuaor CaS;nS Captn ft <br /> I <br /> Well Casing Diameter_:r. Thickness/Gauge/ASTM Schec Steel Plastic Stainless Steet Other I OI <br /> Grout Seal Depth ft Neat Cement(94 ID Jag•';'9,a:rioter) Sand Cement sack mixrl gal water <br /> Bentonite k20%solids) Other <br /> Grout Placement Method Pumped Free Fan Other Retardant!Accelerator(name) <br /> PEDESTAL Installed By Driller Pump Contractor Other <br /> onrrete Pedestal Dimensions:Width_u Len -1- 3 Thi in .Christy Box Stove Pipe <br /> .;'MP Suomersible Turbine Other i--P Pump Se ft Standing Water Level ft 1 <br /> HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> OAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> ::URRENT AND C WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT IAM IN COMPLIANCE WITH ALL <br /> .YORKERS COM ON LAWS. �� <br /> MINI 4 HO ADVANCE NOTICE REQUIRED'FO?CMUS PEC_ TIONS_PLEASE-CALL(209) 3 697 <br /> S!GNED I 1 �( rn.(.W (J Lq <br /> TIrL- DATE <br /> I i I t <br /> I <br /> l PAy <br /> Ali <br /> 2019 <br /> l i CNV Qv�N <br /> i cq=��RONM�COO <br /> I `vr <br /> _ <br /> �P-_ALTMENT u E NLv <br /> -a <br /> ADOnC,e:IGn ACC20[QC isy <br /> Area �Ze Employee!D+-� <br /> ro :inspeC.Icr.d, SPECIAL Well Permit <br /> o..Tc Inspection By _ate 1 <br /> WAVER Received <br /> 9.n�gInspection By <br /> DataConstructed Weil Depth h <br /> 'c es 5o ; Received he Amount D Ce Permit/ <br /> ash itted Service Re uest 7i Invoice# I Well ID# <br /> i � I <br /> i <br /> I <br /> WELL'OJMf`ritldi <br />