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--'"ROhwENTAL WEAL/P i'� <br />I�� UNDggLE PEgM1T HEALTIIDEPARTMENT SMP PERMIT <br />�REsa 7 --1�4_ 18gQ EAbT HAZELTON AVENUE - STOC1rTOry —CA <br />ICR03S$T K� wW__;SbOV_Org/ehdoto' <br />BEET t b-�.---V - -- EXPIRES 1 (2I <br />OVNER NAPE t7 - CITY/Z1P - Yom' FROM 1)ATIJ <br />• 1 (, e, C,c PAkCEI. $IIE <br />a'VNERQDORESS L12d 1-AhoUSE APPUCATIgq E <br />CONTRACTOR PHCNE <br />1 <br />CONTRACT,,,CITY/STATEZP--- <br />t �1 • � � <br />ADDRESS ^ <br />PHONE 3 c: q - � 7 7 Cj <br />SUBCOMRACTOR/CONSULTANT J -'- CITY/STATE(LP �c�' -}- r, <br />SUBCONTRACTOR/CONSULTANT ADDREss ` A <br />PHONE -- J <br />LICENSE -A C_57 CITY/STATEIZJp -t <br />C-61 D -D9 Other I <br />BILLING PARTY; �� NUMBER 3,11 , ,�y 1) <br />.. OWNER CONTRACTOR EXPIRATION DATE 7 3 I - <br />DOMESTIC SUBCONTRACTOR/CONSULTANT <br />WELL SAMPLINO; It General Mineral/Coliform Bactena 4391 <br />INTEN-USE DomesLUPnvate IrTIgalloniAgncuttural 'Industrial ) Dlbromochloro ro ane (4392) Arsenic (4393) <br />p p <br />Public Water System �/ater Quality Monitoring Soil SamplingrCharaaenzatlon <br />If different frorn Owner <br />Watar System Name <br />TYPE OF WORK Contac Name or Phone Number <br />��- xNeW Well Replacement Well <br />Well Alteration/Modirication <br />Monnonng Well(s) 0 ul wells �- Other <br />Soil Bonng(s) _ rrorbonnas <br />Out -Or -Service Well Out-Ot-Service Wel I -Geotechnical_ <br />tl ol6onnps <br />New Pum Pum Re lacement Cross Connexion Repair <br />WELL CONSTRUCTION Pum Re air <br />Raise Well Casing <br />DrillingMethod XMud Rotary Air Rotary - Auger Cable Tool Proposed Well Depth 3e, Push Point - Other <br />R Excavation —� in diameter <br />Conductor Casing i Open Bottoms Gravel Pack/Gravel Size t <br />9 m diameter / Conductor Casing Depth --__ft —Li— in diamete <br />Well Casing Diameter � 1n Thickness/Gauge/ASTM Sched , � -� <br />Grout Seal Depth C l ft z' Steel X Plastic is Stainless Steel Other <br />Neat Cement (94 Ib bag/5.10 gal wale. <br />Bentonite (20% solids) Other ')4 Sand Cement G . S <br />Pu Cement. mrr 7 gal water <br />Grout Placement Method <br />Pumped 1 Free Fall Other <br />PEDESTAL Installed By Driller�— Retardant / Accelerator (name( <br />Pump Contractor Other <br />xConcrete Pedestal' Dimensions. Width <br />—.4 ft Length % R Thick Christy Box =Stove Pipe <br />PUMP Submers ble Turbine <br />Other HP I'' Pump Set rt`Q'F1 THAT I HAVE Standing Water Level -i < C, ftS <br />APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br />JVMyV Iv -,v�nr 1 VRUIf4AIN <br />Lco' <br />JIMrc LHVYJ, gryU MULCJ MIVU ,rt u` ITIGNS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br />CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE B <br />WORKERS COMPENSATION LAWS. OARD AND THAT I AM IN COMPLIANCE WITH ALL <br />MINIMUM 48 HOUR ADVANCE NOTICE RP I R -r c <br />_QJI. tJ FOR INSPECTIONS -PLEASE CALL (2t79) 553-7697 <br />SIGNED_ /7r J <br />-}. TITLEy - t I' c .I !1 e'ni DA TE _i-, -.rr, f• <br />Ul <br />T <br />3l <br />DEPARTMENT USE ONLY y <br />7 ® <br />�,� 7 Enr=ovo^- IDs D�_ APPhadrun A;-cePted By .. <br />(ir uul hmport, n Dat. SPECIAL ii�Bi i a1un� <br />y Iv s� Derr _�� <br />hump Ineper:Ilan By W1/A1VER RCCEIVCd <br />'end l.�nnDate ----------- CwsWc"Wen Depth n <br />E& MMI 14 I r t1 Inapn inn Ny Date <br />IN <br />111 <br />i c t P5 $ -- - - --? <br />I J "-T <br />1 <br />t 1 1 4 If 5 0 _. t� -' t 1 I IF _ <br />