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SAN JOAOUINCOUNTY ENVIRONMENTAL HEALTH DERAR WELUPUMP PERMIT <br /> 1668 EAST HAZELTON AVENUE-STOCK-TON CA 95205-(209)4683420 <br /> NON-REFUNDABLE PERMIT CALL(209)953-7697 FOR INSPECTIONS <br /> JOB ADDRESS -0 I R EXPIRES 1 YEAR FROM DATE ISSUED <br /> CITY21P N <br /> CROSS STREET Ahem, g —I� ApN -I DD <br /> SIZE LAND USE APPLICATION# <br /> OWNER NAME - C ell y s O <br /> 3 <br /> OWNER ADDRESS _ PHONE,2�U - <br /> CONTRACTOR CTTYJSTATE21p1GHFtA LTV 7IJ nC t v <br /> CONTRACTOR ADDRESS PHONE V �• <br /> O_ Z <br /> aa <br /> Iq <br /> A 5�J' <br /> SUBCONTRACTOR <br /> PHONE <br /> SUBCONTRACTOR ADDRESS <br /> CrrY/STATEJZTJP <br /> LICENSE YC-57 D C-61 D D-09 U Other NUMBER ((ry}} — <br /> ////7����t'''''TTTT <br /> ExPIRATION DATE •3 y 7,f� <br /> DOMESTIC WELL SAMPLING; General Mineral/Coliform Bacteria(4391);kDibromochloropropane(4392)U Arsenic(4393) <br /> INTENDED USE DOmestlC/PrlVale H Irrigation/Agncullural -1Industrial E Water Quality MOndOring D SOII Sampling/CharactOdZahon <br /> rI Public Water System <br /> e 5nererfl from Omer Waley System Name Centap Name or P—Numeef <br /> TYPE OF WORK New Well Replacement Well D Well AlteraborUModification f7 Other <br /> O onitonng Well(s) #of wells U Sod Bortng(s) a°f D-ng, ❑Geotechnical a of boring, <br /> ❑Out-Of-Service Well D Out-Of-Service Well Renewal _1 Cross-Connection Repair <br /> D New Pump I Pumip Replacement D Pump Repair Well Casm <br /> WELL CONSTRICTION <br /> Drilling Method)<Mud Ro 11 Air Rotary C Auger D Cable Tool ^Push Point F Other <br /> e <br /> Proposed Well Depth'.3& ft Excavation�_In diameter C Open BottomG ravel Pack/Gravel Size in diameter <br /> D Conduct Casing in diameter / Conduct(pp'r'�a1sing Depth ft <br /> Well Casing Diameter In Thickness/Gauge/ASTM Sched�2 — -1 Steel Mastic :.Stainless Steel ;Other <br /> Grout Seal Depth,_ ft Neat Cement(94 Ib bag/5-10 gal wator) Sand Cement sack mlxr7 gal water <br /> )L,Bentonite(20%solids) 0 Other <br /> Grout Placement Method Pumped U Free Fail II Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By -1 Driller C Pump Contractor 11 Other <br /> 0 Concrete Pedestal ODlmensions.Width_R Lengthft Thick in 0 Christy Box r.Stove Pipe <br /> PUMP nnnn�i�S1utmerssibloo Turbine D Other HP h <br /> Pump Set ft Standing Water Level <br /> 791 I I'1}IVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> REQUIRED <br /> CENE 15 <br /> CURRENT AND COUNTY <br /> ACTIVE ORDINANCES <br /> STATE <br /> NTH THECALIFORNIA CONTRACTORS STATE LICENSE BOARD AND CERTIFY Y ( <br /> THAT AM INCOMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS, <br /> MINIM ANC ICE REQUIRED FO I,N�1SPEC I NS PLEASE CALL(209)953.7697 <br /> '�/�� <br /> TILE f IL11N�/ DATE ,O•\110. /I/ <br /> SIGNED — <br /> _ ECMENT <br /> EI V ED <br /> I <br /> CT 12 2020 <br /> �ROtiM OOUNTy <br /> EN TA L <br /> Fi DEPARTMENT <br /> t <br /> DEPARTMENT U S E O N L Y 7 ^A <br /> - - I <br /> Application Accepted By Date Area Employee ID# U <br /> _. <br /> Grout Inspection By Date ' SPECIAL Well Permit <br /> Pump Inspection By Date WAIVER Received <br /> Soil Boring Inspection By <br /> Date Constructed Well Depth it <br /> COMMENTSNDT�0„ O OtC�SO�a St rl <br /> A Sc Received Check#I Amount Date Permit/ Invoice 0 Well ID# <br /> Info ash Remitted erir R usat#O . ISO <br /> b o12• <br /> WELL RUMP PERMIT <br /> E1D43416 =1/17 <br />