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WELL/PUMP PERMIT <br /> ?GAQUiN COUNTY ENVIRONMENTAL HEALTH DEPARTME-1,1 i- -I Bed EAST Flruri-TON AVENUE-STOCKTON CA 95205-62'32 (209)468-3920 <br /> * -RI'Ft,INt?ABLE PERMIT vV.S ov.ar )zhf11 EXPIRES Y <br /> v�.lv�3EAR FROM DATE ISSUED <br /> rrv2I m <br /> r. p.,�RE83 1441 al fi" ---- C1P <br /> iy5 3TRfiE7" �✓ 1 AlPN %0�.1/_�•!!.--.PARCEL SIZE0jaelLAND USE APPLICATION# � <br /> 11 <br /> S♦ CITY/STATEIZIP <br /> a ® <br /> i 4 <br /> C'lOR PIiCNE !) �.• ` � <br /> ::,4CrOtt ADDRESS *9rfYl�iTATEIG IP �i8i I <br /> :: -.._-Ni r:,a:TCtfiCC3;tSU1.TAPIT •--- �'r7(7iVL"�-(�����'�T'— <br /> ..M'rQAuTURI NSULTANT ADDREaJ CITYISTATEIZIP <br /> t:Fi`c+ii -57 :: C-61 .: D-09 Other NUMBER EXPIRATION DAT � <br /> t"ARTY: C'OWNER 001ONTRACTOR SunCONTRACTOR/CONSULTANT <br /> Virt t.SA1,APL1No:--!General Mineral/Coliform Bacteria(4391)_ Iibromochloropropane(4392) Arsenic(4393) <br /> uts i tai Domestic/Private irrigation/Agricultural Industrial Water Quality Monitoring ' Soil Sampling/Characterization ! <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> :•__,._ ' ass New Well Replacement Well Well Alteration/Mod fication Other <br /> Monitoring Well(s) #of wells Soil Boring(s) #or borings Geotechnical_ #of borings <br /> Out-Of-Service Wel Out-Of-Service Well Renewal Cross-Connection Repair <br /> New Pump ump Replacement Pump Repair Raise Well Casing <br /> �__�.,.';r!vSl'rfUf TiUPTiUP; <br /> +;et°roes :: Mud Rotary Air Rotary 'Auger Cable Tool Push Point Other <br /> vVell Depth ft Excavation in diameter . Open Bottom Gravel Pack/Gravel Size in diameter <br /> onductor Casing in diarnPter / Conductor Casing Depth ft <br /> rtsing Diameter_in Thickness/Gauge/ASTM Scher_i ;feel _ Plastic ; Stainless Steel Other <br /> :,},al Depth ft Neat Cement(94 th bay/5-90 gal water) Sand Cement sack nix17 gal water <br /> Bentonite(20%solids) , Other i <br /> .. ^!?-YY=enk Method ,: Pumped Free Fall Other • _�•, Retardant/Accelerator(name) <br /> Installed By ii Driller Pump Contractor Other <br /> Concrete Pedestal..Dimensions:Width ft Length It Thick in Christy Box Stove Pipe i <br /> ­bmersiblel Turbine :_ Other HP Pump Set Zbh _ft Standing Water Level ft <br /> CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> 1nr ':3;J llTY ORDINANCES, STATE LAWS, AND RULES AND REGULATlON5, I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> ACTIVE WITH THE CALIJORNiA CONTRACTORS STA'.'c LICTRiSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> N1UlN 48 O t E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209)953-7697 f <br /> Ir <br /> mss. y <br /> TITLE 'i�'1-� --_ DATE <br /> !-- • <br /> _ i YME <br /> AG <br /> i10 <br /> 8 ?0?p <br /> /N <br /> qFCO tNTY <br /> UL:i'f',i� T I-NT 4I ;E 0 M L Y <br /> ,Pit<?tiori -epted __ Uato __ _ Area _ E loyee is <br /> incpe 'o By —_ to I SPI I -111 Pe tt <br /> J DEPARTMENT USE ONLY <br /> Application Accepted By 1---l-117v Date Y ZZoZo Area N --i�� Employee ID# DA <br /> Grout Inspection By Date _' SPECIAL Well Permit <br /> II11 t <br /> Pump Inspection By G(h A'ht-)( j2=jetit ,t Date I WAIVER ReCeived <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE Sc Received ChecqW Amount Date Permit/ Invoice# Well ID# <br /> Codes Info B ash Remitted Service Request# <br /> 38) 0:50 �7 7 1 )71 5 <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />