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• WELLIPUMP PERMIT <br /> JOA(JUHN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1668 EAST HAZELTONIAVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> N, N-REFUNDABLE PERMIT 1J'VVVW.sjqov.oj-g/phd EXPIRPS I YEAR FROM DATE ISSUED <br /> Ax)RESS q91 !'iTY/Zir <br /> 1-!qon3 STREET <br /> WWI P:RvQf� LAND USE APPLICATION 9 <br /> m <br /> -iPn NAM- M PHONE cNn <br /> "_ VA <br /> RACTOR ADDRESS CITY/STATE/ZIP JjI L c- A /old <br /> :­,JG".NTRACT0R��ONSULTANT ADDRESS CITYISTATE/ZIP, <br /> q V.G.57 C-61 D-09 Other NUhlrat R EXPIRATION DATE3&/jZ__ <br /> C.",A RTY: ;.1 OWNER :641ONTRACTOR SUSCONTRACTOR/CONSULTANT <br /> SAMPLING::1 General Yi/neral/Coliform Bacteria(4391)--- Dibromochloropropane(4392) Arsenic(4393) <br /> L11--rin-ILSE: Domestic/Private Irrigation/Agricultural ' Industrial Water Quality Monitoring F, Sol[Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> Now Well Replacement Well Well Alteration/Modification Other <br /> Monitoring Well(s) #of wells Soil B ring(s) 41 of borings Geotechnical #of borings <br /> Out-Of-Service Well -Service Well Renewal Cross-Connection Repair <br /> New Pump Pump Replacement PumpRepairRaise Well Casing <br /> ~Bing Method .: Mud Rotary Air Rotary ! Auger Cable Tool Push Point Other <br /> Depth ft Excavation in diameter . Open Bottom Gravel Pack/Gravel Size in diameter <br /> I. Conductor Casing_in diameter I Conductor Casino"Depth 'it <br /> anIng Diameter in Thickness/Gauge/ASTM Sched Steel -, Plastic :.. Stainless Steel <br /> Other <br /> .U!.;al DepthftNeat Cement(941b bag/5-90 qa/water) Sand Cement sack mix17 gat water <br /> i3entonite(20%solids) 7 Other <br /> t4coment Method .i Pumped :; Free Fall . Other Retardant I Accelerator(name) <br /> Driller <br /> Installed By Pump Conti-actor Other <br /> Concrete Pedes Dimensions:Width ft Length Ft Thick in Christy Box ..: Stove Pipe <br /> Submersible-Vurbine :-! Other <br /> HPPump Set ft Standing Water Level <br /> ft <br /> GERTIF',' THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> -,t`A1NT'e' ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> N <br /> ACTIVE wrrH THE CAL 0 RNIA CONTRAC",'ORS STAT7_ 1_IPE?jSr. BOARD'AND THAT I AM IN COMPLIANCE WITH ALL <br /> 'R_� PENSATI N <br /> UM 48 E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> 44�_ e I TITLE_ DATr. <br /> T7 <br /> -—--------- <br /> \1 rv, <br /> I 6AI. <br /> ATYM.CrA,, <br /> -%IV <br /> li <br /> A <br /> vti) <br /> APPI <br /> W�0 EQ <br /> Q <br /> e-, <br /> /V <br /> AL <br /> DEPARTMENTZ S� ONLY <br /> /,fq <br /> ;�7 2 1 2�0 <br /> Application Accepted By Date 2 '0 Area LiEmployee ID# <br /> Grout Inspection By Date 0 SPECIAL Well Permit <br /> Pump Inspection By 9.(,L Date (OW 20— 0 WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received e!ahec. Amount Date Permit/ Invoice# Well ID# <br /> w <br /> Codes Info B Cash Remitted i Service 2auest# <br /> 477 !P1 IA)V1)jAV_7V't <br /> EFID 43-06 6111/2019 WELL/PUMP PERMIT <br />