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V i11E-1,L.J'P U Rvl'l F 1 P d i`,,Ail 0 T <br /> 1 'JACIURN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 2)il`,'AST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> v <br /> 1,,)3a-REFUNDABLE PERMIT 1A1WVV.q-JCa00'v'."-' rqle h d Fca,4 FRIES 1 71'1-:.AR FROM DATE ISSUED <br /> rJ9 ADORES' 4 <br /> �7—o4(1,gq— m <br /> ry,EL SI2E5Nr—AND USIF APPLICATION <br /> rn <br /> 'JER NAP?- API? PA--_2 At- <br /> CnYlSTATEl72iP-7LN i <br /> RACTORnw)NE P-0 <br /> - <br /> �:.),.NTRACTOR ADDRE383YSA7P1T / TTE11L ^ I Aid <br /> TRACTORICONSULTANT PHONE <br /> NSULTANT ADDRESS CITY/STATEIZIP <br /> -57 C-61 <br /> D-09 Other NUMBER215%3. EXPIRATION DATE <br /> .as PARTY: .-J OWNER 'TRACTOR SUBCONTRACTOR/CONSULTANT <br /> General Mineral/Coliform Bacteria(4391)_7 Dibromochloropropane(4392)'7 Arsenic(4393) <br /> L, ,WELL SAMPLING:�j <br /> _rlun LIS Domestic/Private Irrigation/Agricultural Industrial ' Water Quality Monitorinq F',Soil Sampling/Characterization <br /> Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> New Well i Replacement Well Well Alteration/Modification Other <br /> # <br /> Monitoring Well(s) ft of wells Soil Boring(s) #of borings :: Geotechnical of borings <br /> Out-Of-Service Well Out-Of-Service Well Renewal iCross-Connection Repair <br /> New Pump Pump Replacement Pump Repair Raise Well Casing <br /> QONSLRUCTION <br /> -Method : Mud Rotary Air Rotary Auger Cable Too] Other <br /> .: Pugh Point <br /> -;Ili4d Wall Depth It Excavation in diameter Open Bottom -- Gravel Pack/Gravel Size in diameter <br /> L! Conductor Casing_in diameter Conductor Casing Depth ft <br /> 111 Casing Diameter in 'Thickness/Gauge/ASTM Schad Steel 71 Plastic I Stainless Steel Other <br /> owokit;3zal Depth - -ft Neat Cement(94 1b bag/5-10 gal water) Sand Cement sack mix17 gal water <br /> Bentonite(20%solids) 7, Other <br /> t2l Piqcernent Method-.-, Pumped .i Free Fajk i.. Other Retardant/Accelerator(name) <br /> _'_;tS1 AL Installed By Driller <br /> 1 4ump Contractor Other <br /> Concrete Pedestal ,Dimensions:Width AL ft Length It Thick in Christy Boic Stove Pipe <br /> SLI)mersiblelefurbine ',- Other HP Pump Set- 3W ft Standing Water Level ft <br /> 4�:REBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> IFI COIJPITY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> ANIIIIIACTIVE tAVITH THE CAL ORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> Ic <br /> '61iEtl". Tl <br /> M E NOTICE REQUIRED FOR INSPECTIONS-PLEASE CALL(209).963-7697 <br /> V14-'�p <br /> TITLE.. DATE <br /> C-1 <br /> L I I <br /> A 12 <br /> 'j <br /> k A W <br /> 2' <br /> OUN <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date -11LISIA0 dQ Area gmployee ID# FiQ <br /> Grout Inspection By Date 0 SPECIAL Well Permit <br /> Pump Inspection By reg 3 f cc- Date q/i- o 2-y [I WAIVER Received <br /> Soil Boring Inspectiony Date Constructed Well Depth ft <br /> COMMENTSr <br /> Sc Received Permit/PE j-.Eec Amount Date PerInvoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> qago o:s, qcl Lia #Iso— I L1 <br /> 4-77 — <br /> re.-n- <br /> S'i Colk -Z- <br /> 1 er7w 0 K <br /> EHD 43-06 6111/2019 WELL/PUMP PERMIT <br />