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Is <br />WELUPUMP PERMIT <br />SAN JOAam Coutm Env■eonre+rAL HmTH DEPARTIE.NT 1868 EAST HAZELTON AVENUE - SmcKTON CA 95205.6232 (209) 4663420 <br />NON-REFUNDABLE PERMIT' wwwsjgov orglehd EXPIRES 1 YEAR FROM DATE ISSUED <br />.`-_%leJ t f CITr)ZP 366 <br />JOB ADDRESS�[a4d <br />CROs STREETL-r nI D <br />PARCEL S�1.:, LAID USE APPLICATION # p <br />Ai� �% v <br />OWNER NAME r l r ,r PHONE ur- 8 _ -�^ <br />OWNER ADDRESS _ _ ••••••�••••�• _ <br />CONTRACTOR P. 1�\l- -� <br />CONTW�CroRADDrtL- li ox ci—o CrtYiSfArEIZs <br />SURCONTRACTORICONSULTANT <br />Suscom RAcToR/COwsuLTAuT ADOREss <br />LICENSE C-57 3/G.61 = D-09 -1 Other <br />PARTY: i OWNER <br />C CONTRACTOR <br />_ CnVSTATE%IJP <br />NumaERti0 " 1_��`7 <br />SUBCONTRACTOR/CONSULTANT <br />EXPMTM DATE_ <br />DoMesne WELL S. iPLehc;_ General Mineral/Coliform Bacteria (4391) U Dibromochloropropane (4392) Arsenic (4393) - <br />ENp ;P USE DomestirJPri�rate 7 li igabowAgricutlural C Industrial C Watsr t]uality Monitoring ❑Sal Sampling/Charadenzahon <br />Public Water System___ _ <br />M Galli M 1 0—Waw Systan Narro G—t a Nen. or Ph— Number <br />TYPE OF_WORK „ New Well w•itepi,-"ment Well I Well AfterabaYModif-icatwn 1 Other <br />i Monitoring Well(s) # of webs Soil Boring(s) a or borvgs i Geotechnical • °t txuvgs <br />1 i Ou14Service well Out -Of -Service Well Renewal ' Cross -Connection Repair <br />ew Purtro ' I PumD ReDlacement Pump Repair i I Raise Well Casing <br />Drilling Method i : Mud Rotary IAir Rotary i Auger ; Cable Tool : I Push Point i i Other <br />Proposed Well Depth_ft Excavation in diameter ii Open Bottom C Gravel Pack/Gravel Size in diameter <br />Uj Conductor Casing. in dianreter / C Axkrdor Casing Depth _ ft <br />Well casing Diameter _ in Thkdotesa/Gauge/ASTM Schell _ Steel ❑ Plastic C Stainless Steel = Omer <br />Grout Seal Depth R r, Neal Cement (94 /b bag/5-10 0 wale() n Sand Cement sack mire gal water <br />I i Bentonite CZ0%solids) ' Other <br />Grout Placement Method --Pumped = Freo Fall 7 Other Z Retardant I Accelerator (name) <br />PEDESTAL installed By 7 Driller C Pump Contractor 7 Other 10"Jo a y- _ <br />I ConVWm Pedit-W ; Dimensions: Width ft length R Thick in r Christy Box ;Stove Pipe <br />i . • . . 1 1 Mijila,: • • • . • h <br />�■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■� ■■■" <br />■■■■I�I�l�111111�IL�l`.i■■■■■■itiw•i■�■■■■I■■■1�■J■■■■■■■■ <br />DEPARTMENT USE ONLY <br />Application Accepted By `-.. Date •� Lj ,ul Area P (�/ Employee ID# t f� <br />Grout Inspection By Date D SPECIAL Well Pennit <br />Pump Inspection By �_ Date Z ` 0 WAIVER Received <br />Sod Boring Inspection By Date Constructed Well Depth tt <br />COMMENTS NyQ we 1 SL S <br />r7w41s1111 d112ote WELLIPUWPERMR <br />Ty <br />r <br />=®VMAW_77, AFA <br />r7w41s1111 d112ote WELLIPUWPERMR <br />Ty <br />r <br />