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e <br /> r f <br /> ✓ WELL/PUMP PERMIT <br /> i <br /> 1868 EAST HAZELTON AVENUE•STOCKTON CA 95205 (209)4e{-3420 <br /> t <br /> OAOUIN COUNT/ENVMtOreIENTAL HEALTH DEPARTMENT <br /> NON-REFUNDABLE PERMIT CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOeADDRESS i ^� /�i F �/�•�- I� 1. CITYMP %�. r� /l' � <77 1 <br /> _ r <br /> CROSS STREET !/�(`/f �` �}A �•/ %�• /ArPN,/ I(-' •'�` t t PARCEL SIZE 'LAND USE APPL'I)CATION N/ ` <br /> OWNER NAME 142 y/!�lJf �y ,/J �. .'+�(f(/L /V/1 �S. PHONEL' <br /> Owner ADDRESS `Nr����/f! CRY/STATEILP �y / <br /> LOrtTRACTOR Amiv i /' t/t^,f�•'' 2i' . I`-i/i PHONE <br /> II6ONTRACTOR ADDRESS / t �....? Ctrr/STATEMP <br /> SU.SgONTRACTOR I A'5;t l L l ey ,G.7/J, //-/-I/�J PHONe <br /> I6UflG TPJICTORADDRESS CITYISTATEfLP <br /> I `U*r-57 d 6-67 <br /> 00-09 O Other NureeR EXPIRATION DATa <br /> DOMESTIC WELL SAMPUNG:0 General Mineral/Coliform Bacteria(4391)0 Dibromochloropropone(4392)0 Arsenic(4393) <br /> INTENDED USE DomestirJPNYate 0 Imgatlon/Agricuhural 0 Industrial 0 Water Quality Monitoring O Soil wnSarnpling/Ch <br /> 0 PUblic Water System AL'�E <br /> rc different Gam Owner: WSW System Name Correct aet Naor Phone <br /> TYPE Or WORK 0 New Wew eplacement Well D Well AnerationMlodification U Other MA <br /> 0 MonRoring Wells) X of wells 0 Soil Boring(s) a olborlrge 0 <br /> _ Geotechnica414LIW <br /> 0 Out-Of-Service WeRenwerConneSoR .�OCOUN] <br /> ye�� lCENVin R " <br /> 3�dew Pum0 Pum Replacement ❑PumRe a � y <br /> (WELL COHS7RUC71ON T416011'r <br /> Drilling Method,�lUud Rotary 0 Air Rotary 0 Auger 0 Cable Tool 0 Push Point 0 Other tri <br /> Proposed Well Depth _:31✓f R Excavation /Z- in diameter 0 Open Bottom a- ravel Pack/Gravel Size in diameter <br /> 0 Conductor esing in diameter 1 Conductor Casing Depth tt <br /> Well Casing Diameter in,,_,ThicutesalGauge/ASTM Sched 7L;1 0 Steel,APlastic 0 Stainless Steel 0 Other <br /> Grout Seal Depth _:ft 0 Neat Cement(94 Ib bag/5•10 gal water) 0 Send Cement sack mix/7 gal water <br /> kfBentonite(20%solids) 0 Other <br /> .f3rt,Ut Placement Metlwd.Pumped 0 Free Fell ❑Other 0 Retardant/Accelerator(name) <br /> I MSTAl Installed By ❑Driller JP I ump Contractor 0 Other <br /> 0 Concrete Pedestal UDimenslons.Width ft Length ft Thick in 0 Christy Box 0 Stove Pipe <br /> ubmersible 0 Turbine 0 Other HI Purnp Set ft Standing Water Level > * <br /> 1• EBI-CERTIFY THAT I NAVE ITH PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WSAN <br /> t tt-ho BOUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> REh: AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPUANCE WITH ALL <br /> KERS COMPENSATION LAWS. <br /> MINIM �I9�AOU ANCE NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7 7 <br /> SIGNED_ <br /> �h�J//� I /:? TITLE 1r i i I DATE��T?/ <br /> ;-�... .1 . -yam-L-1- J _ <br /> vii <br /> d r <br /> I <br /> i DEPARTMENT USE bNLY <br /> 1 DlP�A1'1YFEIIT 519'IleI�ty <br /> pficalion BY� Dale <br /> ApArea (� <br /> Grout Inapectan BY -- Date ' 11SPECIALfR1 a . <br /> Pump Inspection By Date 0 WS11VER stt#CAIVA <br /> Soil Boring In " n BY l' •'s Dale <br /> COMMENTS D I/( ti r _ Z�/ <br /> PE SC Received ChecW Amount Date Pennitf Invoice M Wall IDs <br /> Codes info h Remitted Service Request a <br /> f, � I il ;•Ir � <br /> ;1J 7 y <br /> EHD 43-06 M1116 WELL/PUMP PERMIT <br />