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1NELL/PUMP PERMIT <br />SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DEPARP19[r 1868 EAST HAZELTON AVENUE - STOCKTON CA 95205.6232 (209) 468-3420 <br />NON-REFUNDABL FJtMR v.0f /ehd EXPIR S 1 YEAR FR <br />OM TE ISSUED <br />!O8 ADDRESS CnYrZ1P / N <br />:ROSS STREET APP; .S- O — 2PARCEL SIZEl LAND USE /iPPUCATION D <br />f. <br />)WNER NAME <br />)INNER CITY/STATE121P 6RR,il%% /Y-) - <br />LISILUNaPARX.: <br />--CmrISTATErzPNSULTANT <br />PHONENSULTANT ADDRESSATErZrp ❑ C-61 ❑ D-09 U OtherNUMBER EXPIRATION DATE^_ OWNER C CONTRACTOR 7 SUBCONTRACTOR/CONSULTANT <br />DOMESTIC WELL S PLINO: n General Mineral/Coliform Bacteria (4391) Dibromochloropropane (4392) ❑ Arsenic (4393) <br />INTSNoeoUeE DomesttcPrivate ❑Irrigation/Agricultural Industrial r WaterOuelftyMonitoring G ShcSampfing/Character¢ation <br />C Public Water System <br />If Waarent from Owner. Water8yslem Name <br />CoMeci Nene or Phone Number <br />TYPE OF WORK New Well Replacement Well = Well Alteraflon/Modirirallon C: Other <br />Monitoring Well(S) # Of Wells a Soil BOring(s) S Of borings Geolechnical fr of bodngs <br />Oul-Of-service 9 � Out -Of -Service Well Renewal Cross -Connection R <br />air <br />— 'New Pump , _ r, <br />_ Pump Replacement P.- P-,1_ ... ..... _ ep <br />Drilling Method -- Mud Rotary C Air Rotary Aug?r 7, Cable Tool Push Point Other <br />Proposed Well Depth_ft Excavation in diameter _ Open Bottom a Gravel POCk/Gravel Size <br />C Conductor Casingin diameter <br />In diameter / Conductor Casing Depth fl <br />Well Casing Diameter _ in Thldmess/Geuge/ASTM Schad Grout Seal Depth = Steel D Plastic 'j Stainless Steel _ Other <br />P ft _ Neat Cement (94 Ib bag/5-10 gat water) '1 Sand Cement <br />Bentonite (20% solids) Other sack m/x/7 gal water <br />Grout Placement Method Pumped = Free Fall � Other <br />EDESTAL Installed By - Driller _ Pump Contractor - Other <br />Concrete Pedestal GDlmeneions: Width ft Length fl Thick in _Christy Box =Stove PI e <br />Submersible Turbine -Other HP Pump Sel R Blending Water Level <br />I HEREBY CE TIF THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />CU R IN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. 1 ALSO CERTIFY THAT INY REOtIIRFn 1 it er ce <br />CURRENT AND ACTIVE WITH THF caf fFnoure r. __-_ <br />y2��'d^�'Th'%i-L--�i rvt c ry I 1.14h N LY <br />Application Accepted B i <br />Dal -/4421 Area Employee ID# <br />Grout Inspection By Date ❑ PECI L Well Permit <br />Inspection By - YLEJ� Date _ <br />' <br />Soft Boring Inspection By Date ConstWAIVER Received <br />Constructed Well Depth <br />COMMENTS ft <br />WELL /PUMP PERMrr <br />