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I �� '% <br /> f % WELL.1PUMP PERMIT <br /> 'AQU;N(COUNTY ENVIRONMENTAL HEALTH DEPARTMENT -I 8G3:AST HAZELTON AVENUE-Fu'TOCKTON CA 95205-6232 (7.09)468-3420 <br /> :`i-REFUNDABLE PERMIT 1Aft+,r'y'3 ®i:.Ol' 1and EXPIRES 9 YEAR FROM DATE ISSUED <br /> r7 <br /> LAI <br /> j y6 06 «fit --_ _-- CITYIZIP �^/�� �`����T— m <br /> -;33 STP.Etr a1PPf -.0Aq--_PAR9,EL SIZE LAND USE APPLICATION# <br /> m <br /> NAMQ Ccs <br /> "'AV-33 ` - -,rYISTATE/ZIP (_(� <br /> I, P11 10ME <br /> :,tTP';isi ADQREu1 R. _.....-- _-- :'I F /STATEIZIP / �+ <br /> . .;6.TOR/rCNSUI_T ANT PHONE <br /> .,Tt•.:\i;TGr( P73ULTANTADDRE55 r"i'rYiSTATE/ZIP <br /> I <br /> •57 C-61 D-09 Other__ Ni+IntaER t� EXPIRATION SiATFI: /4 — <br /> 'i^'Y: OWNER :*et;TRA.CTOR SURCONTRAC,'CRICONSULTANT ! <br /> ;T: 9;F.Li.SAMPLING:=General eral/Coliforrn Bacteria(4391)= nihrornochloropropane(4392)':..'Arsenic(4393) <br /> a-nastic/Private n•igation/Agricultural industrial Vvntuf ovality Monitoring '. Soil Sampling,/Characterization III <br /> Public Water System I <br /> If different from Owner: Water Sy3tem Name Contact Name or Phone Number <br /> Now Well Replacement Weli �PJPU Alteration/Modi;i::atior Other <br /> i <br /> f borings #of borings <br /> Monitoring Well(s) #of wells Soil Boring(s)Boring(s) #oGeotechnical., �/� <br /> Out-Of-Service Well -Of-Service Weil Renewal : Cross-Connection Repair R - yArl <br /> Pump Replacement N <br /> tiaw Pump Pump Repair Raise Well Casing _ C'��V� <br /> _ ^1N:iTRUCTION /� O <br /> -- -%Iptnod _ :Mnud Rotary Air Rotary Auger Cable Tool Push Point Other S �r� ?020 <br /> c; :aell Depth ft Excavation in diameter C)pun BottomGravel Pack/Gravel Size AMAjarecter <br /> Conductor Casing in diameter 1 conductor Casirr^es,th ft NEgL V/RAN N COU <br /> uatil>tiq Diameter— in Thickness/Gauge/ASTNJ Sched cIleel Plastic Stainless Steel Other T1/�Rn ENTq�Ty <br /> seal Depth ft Neat Cement(9.1;.; ag15-10 gal water) Sand CementT <br /> sack mix17 gal water <br /> RMENr <br /> tentonite(20%solids) Other <br /> «a;<mient Method .: Pumped .I Free Fall Other •___ _ Retardant/Accelerator(name) <br /> .a, installed By ::: Driller Pump Contractor—� Other�-- <br /> 4:onc_rete Pedestal .Dimensions:Width,__ it Length_ R Thick— in Christy BOA Stove Pipe <br /> >-,bmersible!' urbine .. Other-^ HP - - — ^1'.an a Sei —ft Standing Water Level ft <br /> :S3'ti ,rF_Et'TIi " TI?AT I HAVE PREPARED THIS APPS ff'ATION AND THNr Tl;r WORK WILL BE DONE IN ACCORDANCE WITH SAN t <br /> f RDPNANCES, STATE LAWS, A-W RtPL-:S AND REGUL.^.Ti`3:!S. I ALSO CERTIFY THAT MY REQUIRED LICC-NSE Is ' <br /> =P:r .'M AC71VE WITH THE CAI. ORNIA CON i RACTORS STATE i.i:.•i`:5 i3OARD AND THAT P AM IN OMPLIANCE WITI3 ALL <br /> -13SA PENSt,°TIQ1\1I_t ° <br /> UM 48 4D , E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 <br /> DArE ._ <br /> I <br /> I <br /> -- I Tj - <br /> i <br /> i I <br /> DEPARTMENT USE ONLY <br /> l' n <br /> Application Accepted By v Date q ZDV Area y ��( Employee ID# DA <br /> Grout Inspection By pp Date D SPECIAL Well Permit <br /> Pump Inspection ByDate K W ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received heck Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B Remitted Service Re uest# <br /> $d -os-8 as f-7-7 y <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />