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. c r WELLIPUMP PERMIT 41AN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1666 EAST'HAZELTON AVENUE-STOCKTON CA 95205.6232.(209)466-3420 � ;sREFUNDABLE PERMIT r af#twV9.5(g0ir.u4fg13(3d EXPIRES I YEAR FRoiA DATE ISSUED � _Ave nc+ _ _ Q_ CITYIZ _ ._ ! m DRESS I E. - -- n:=; SPRE'_:_S_' \( _1, 4 _Ai'4.Z0Ll I. )_AAt2C EL SI7_EI&Arv_AND U5E fjPPL4CATiON'r/ [a a '..,,.'.R'!A!'.":' _ STY/ S_41.,J`i7b --- IONONE --- •' .STATE/ZIP rao�_vq __.. PHONE s1TYISTATE/ZIP '::, yCiiliF4lISULTANT PHONE _ /57 NSULTANTADDRESS CITY/STATEIZIP Zz�C-61 ;: D-09 ; Other NUMBER EXPIRATION DATE D OWNER O&ONTRACTOR SUBCONTRACTOR/CONSULTANT SAMPLING:-General M'feral/Coliform Bacteria(4391)_ Dibromochloropropane(4392) Arsenic(4393) _# Domestic/Private rrigation/Agricultural Industrial `,Hater Quality Monitoring ' Soil Sarnpiing/Characterization _ Public Water System — — If different from Owner Water System Name Contact Name or Phone Number New Well Replacement Well Well Alteration/Modification Other _ _ Monitoring Well(s) #of wells Soil Boring(s) __ of borings Geotechnicai of borings XO -Of-Service Well Out-Of-Service Well Renewal Cross-Connection Repair ew Pump Pump Replacement Pump Repair Raise Well Casing CNsTRUCTIOIti -ni Method : Mud Rotary Air Rotary ' Auger Cable Tool Push Point Other :;ioseo Yreli Depth ft Excavation in diameter Open Bottom Gravel Pack/Gravel Size in diameter : Conductor Casing in diameter / Conductor Casing Depth ft s1 Casing Diameter_in Thickness/Gauge/ASTM Sched Steel :- Plastic Stainless Steel Other uu;Baal Depth ft Neat Cement(94 lb bag/5-90 gal water) Sand Cement sacls mix/7 gal water Bentonite(20%solids) ' Other Plarcerrient Method .. Pumped ,i Free Fal Other Retardant/Accelerator(name) AL_ — Installed By i; Driller :; Pump Contractor Other _ Concrete Pedestal :Dimensions:Width It Length— ft Thick in Christy Box Stove Pipe hmersible. Turbine :.: Other HF _ Pump Set_ ft Standing Water Level tt 1-EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN ?i1 tf+)UNT`:r ORDINANCES, STATE LAWS, AND I?Ui.ES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS TI°9E WITH THE CAL ORNIA CONTRAC•`PORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL I3>;